tag:theconversation.com,2011:/id/topics/chronic-pain-1044/articlesChronic pain – The Conversation2024-01-31T19:08:10Ztag:theconversation.com,2011:article/2217472024-01-31T19:08:10Z2024-01-31T19:08:10ZA new government inquiry will examine women’s pain and treatment. How and why is it different?<figure><img src="https://images.theconversation.com/files/572314/original/file-20240131-25-o9jwvw.jpg?ixlib=rb-1.1.0&rect=25%2C12%2C4228%2C2812&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-woman-massaging-tensed-rubbing-muscles-2365171835">Shutterstock</a></span></figcaption></figure><p>The Victorian government has announced an <a href="https://www.health.vic.gov.au/inquiry-into-womens-pain">inquiry</a> into women’s pain. Given women are disproportionately affected by pain, such a thorough investigation is long overdue. </p>
<p>The inquiry, the first of its kind in Australia and the first we’re aware of internationally, is expected to take a year. It aims to improve care and services for Victorian girls and women experiencing pain in the future.</p>
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Read more:
<a href="https://theconversation.com/there-is-overwhelming-gender-bias-in-the-ndis-and-the-review-doesnt-address-it-220042">There is overwhelming gender bias in the NDIS – and the review doesn't address it</a>
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<h2>The gender pain gap</h2>
<p>Globally, more women report chronic pain than men do. A survey of over 1,750 Victorian women found 40% are living with chronic <a href="https://www.premier.vic.gov.au/gender-pain-gap-revealed-and-women-arent-surprised">pain</a>. </p>
<p>Approximately <a href="https://pubmed.ncbi.nlm.nih.gov/36038207/#:%7E:text=About%20half%20of%20chronic%20pain,a%20higher%20prevalence%20in%20men.">half of chronic pain conditions</a> have a higher prevalence in women compared to men, including <a href="https://academic.oup.com/painmedicine/article/22/2/382/5961453">low back pain</a> and <a href="https://www.mdpi.com/2077-0383/10/14/3178">osteoarthritis</a>. And female-specific pain conditions, such as endometriosis, are much more common than male-specific pain conditions such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894747/">chronic prostatitis/chronic pelvic pain syndrome</a>. </p>
<p>These statistics are seen <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/stressors-and-bodily-pain/latest-release">across the lifespan</a>, with higher rates of chronic pain being reported in females <a href="https://www.sciencedirect.com/science/article/pii/S0304395911004751?casa_token=fDkFvlrL930AAAAA:SonUMuMgqohViJ2Ok9gGQ7K4G0hChxZYolroR7t5LVSd_uzMnSe_2EBZ4b8blh3GscewZ1bI7Ac">as young as two years old</a>. This discrepancy <a href="https://www.aihw.gov.au/reports/chronic-disease/chronic-pain-in-australia/summary">increases with age</a>, with 28% of Australian women aged over 85 experiencing chronic pain compared to 18% of men. </p>
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Read more:
<a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a>
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<h2>It feels worse</h2>
<p>Women also experience pain differently to men. There is some evidence to suggest that when diagnosed with the same condition, women are more likely to report <a href="https://www.sciencedirect.com/science/article/pii/S1526590011008728">higher pain scores than men</a>. </p>
<p>Similarly, there is some evidence to suggest women are also more likely to report higher pain scores during experimental trials where the same painful pressure stimulus is applied to <a href="https://www.sciencedirect.com/science/article/pii/S0304395911007019?casa_token=ZK8PjH4pXUYAAAAA:UI8K8sKlrWM3OCC7qBucplrA-mct4EU5NZUpQsLQ6WooNWlfxC6MCtTdTKmtyQYjh9kcE08okiQ">both women and men</a>. </p>
<p>Pain is also more burdensome for women. Depression is twice as prevalent in women with chronic pain <a href="https://www.sciencedirect.com/science/article/pii/S0033318207710022">than men with chronic pain</a>. Women are also more likely to report <a href="https://journals.lww.com/spinejournal/FullText/2007/05200/Sex_Differences_in_Consequences_of_Musculoskeletal.17.aspx?casa_token=mgToFxqQuiwAAAAA:Plx0N_ILNIVK_D8NDODFYaYi_HDxbZN2enulMAS0VmIwyCNHd3c62lhEDi_AYDw8Dhz7uX2dPIZ3HoqwnuWoanLH">more health care use</a> and be <a href="https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf.aspx">hospitalised due to their pain</a> than men. </p>
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<a href="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman lies in bed in pain" src="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Women seem to feel pain more acutely and often feel ignored by doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-having-stomach-ache-on-1780468907">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/whats-a-tens-machine-can-it-help-my-period-pain-or-endometriosis-201389">What's a TENS machine? Can it help my period pain or endometriosis?</a>
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<h2>Medical misogyny</h2>
<p>Women in pain are viewed and treated differently to men. Women are more likely to be told their pain is psychological and dismissed as <a href="https://www.tandfonline.com/doi/full/10.1080/03630242.2017.1306606?casa_token=twusk7mU5EcAAAAA%3AG--5Y_nl_bDqsR9k4w-fF8sEMGuGiMlrifAGQKC_j6swOBhYdzzwXeXiNUoR4C9vM2CydSppwLN2">not being real or “all in their head”</a>.</p>
<p>Hollywood actor <a href="https://www.independent.co.uk/life-style/health-and-families/selma-blair-ms-misdiagnosis-symptoms-b2454317.html">Selma Blair</a> recently shared her experience of having her symptoms repeatedly dismissed by doctors and put down to “menstrual issues”, before being diagnosed with multiple sclerosis in 2018. </p>
<p>It’s an experience familiar to many women in Australia, where medical misogyny still runs deep. <a href="https://journals.sagepub.com/doi/abs/10.1177/09593535221083846?journalCode=fapa&">Our research</a> has repeatedly shown Australian women with pelvic pain are similarly dismissed, leading to lengthy diagnostic delays and serious impacts on their quality of life. </p>
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<h2>Misogyny exists in research too</h2>
<p>Historically, misogyny has also run deep in medical research, including pain research. Women have been viewed as smaller bodied men with different reproductive <a href="https://www.sciencedirect.com/science/article/abs/pii/S156925580334024X">functions</a>. As a result, most pre-clinical pain research has used male rodents as the default research <a href="https://journals.lww.com/pain/fulltext/2005/09000/the_case_for_the_inclusion_of_female_subjects_in.1.aspx?casa_token=BcqYDDSRxo4AAAAA:nLvLqpNfuwSm6N4n1kn-Wcj4n9HW__ISaNz57PYp0zX8Nfu9a5cWZdJkjCXVXeU_HKjraI5NbND-rqqzanYuF864">subject</a>. Some researchers say the menstrual cycle in female rodents adds additional variability and therefore uncertainty to experiments. And while variability due to the menstrual cycle may be true, it may be no greater than male-specific sources of variability (such as within-cage aggression and dominance) that can also <a href="https://www.nature.com/articles/s41583-020-0310-6">influence research findings</a>. </p>
<p>The exclusion of female subjects in pre-clinical studies has hindered our understanding of sex differences in pain and of response to treatment. Only recently have we begun to understand various genetic, neurochemical, and neuroimmune factors contribute to sex differences in <a href="https://www.annualreviews.org/doi/full/10.1146/annurev-neuro-092820-105941">pain prevalence and sensitivity</a>. And sex differences exist in pain processing itself. For instance, in the spinal cord, male and female rodents process <a href="https://theconversation.com/pain-really-is-in-the-mind-but-not-in-the-way-you-think-1151">potentially painful stimuli</a> through <a href="https://www.nature.com/articles/nn.4053">entirely different immune cells</a>. </p>
<p>These differences have relevance for how pain should be treated in women, yet many of the existing pharmacological treatments for pain, including opioids, are largely or solely based upon research completed on male rodents. </p>
<p>When women seek care, their pain is also treated differently. Studies show women receive <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR6">less pain medication after surgery compared to men</a>. In fact, one study found while men were prescribed opioids after joint surgery, women were <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR17">more likely to be prescribed antidepressants</a>. In another study, women were more likely to receive sedatives for pain relief following surgery, while men were <a href="https://link.springer.com/content/pdf/10.1007/BF00289259.pdf">more likely to receive pain medication</a>. </p>
<p>So, women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched. Women continue to be excluded, dismissed, and receive sub-optimal care, and the recently announced inquiry aims to improve this. </p>
<h2>What will the inquiry involve?</h2>
<p>Consumers, health-care professionals and health-care organisations will be invited to share their experiences of treatment services for women’s pain in Victoria as part of the year-long inquiry. These experiences will be used to describe the current service delivery system available to Victorian women with pain, and to plan more appropriate services to be delivered in the future. </p>
<p>Inquiry <a href="https://www.health.vic.gov.au/public-health/inquiry-into-womens-pain-submissions">submissions</a> are now open until March 12 2024. If you are a Victorian woman living with pain, or provide care to Victorian women with pain, we encourage you to submit.</p>
<p>The state has an excellent track record of improving women’s health in many areas, including <a href="https://www.premier.vic.gov.au/groundbreaking-clinic-improving-womens-heart-health">heart</a>, <a href="https://www.health.vic.gov.au/publications/victorian-womens-sexual-and-reproductive-health-plan-2022-30">sexual, and reproductive health</a>, but clearly, we have a way to go with women’s pain. We wait with bated breath to see the results of this much-needed investigation, and encourage other states and territories to take note of the findings.</p><img src="https://counter.theconversation.com/content/221747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Chalmers receives funding from The Hospital Research Foundation. </span></em></p><p class="fine-print"><em><span>Amelia Mardon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched.Jane Chalmers, Senior Lecturer in Pain Sciences, University of South AustraliaAmelia Mardon, PhD Candidate, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2201792024-01-30T16:16:38Z2024-01-30T16:16:38ZEndometriosis takes almost a decade to be diagnosed in the UK — our research has revealed some of the reasons why<figure><img src="https://images.theconversation.com/files/572134/original/file-20240130-21-1iifrs.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5472%2C3637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Endometriosis can cause severe chronic pain.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-asian-woman-relieves-stomach-pain-2199693477">Drazen Zigic/ Shutterstock</a></span></figcaption></figure><p>Around <a href="https://www.endometriosis-uk.org/sites/endometriosis-uk.org/files/files/Annual%20Report%202018.pdf">one in ten women</a> and people with uteruses in the UK have endometriosis. This disease causes tissue similar to the womb’s lining to grow in other places – such as the ovaries and fallopian tubes. This can cause chronic pain, difficulty getting pregnant, organ damage and fatigue.</p>
<p>Yet despite how common endometriosis is, people who have the disease still wait around <a href="https://www.annalsofhealthresearch.com/index.php/ahr/article/view/111">eight years on average</a> to be diagnosed.</p>
<p>There are numerous, <a href="https://journals.sagepub.com/doi/full/10.1177/0959353519826170">complex reasons</a> for this delay. A <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002937819303850?via%3Dihub">lack of knowledge</a> about endometriosis by both those affected and healthcare professionals has been suggested, meaning those with symptoms may not know to ask for help – and those that do may receive poor quality care. </p>
<p>We wanted to better understand what barriers people continue to face when it comes to endometriosis care. We used interviews and an open-ended online survey to learn about these experiences. </p>
<p>A total of 33 women completed the online survey – 21 of whom were diagnosed with endometriosis, and 12 who were seeking a diagnosis. We also conducted in-depth interviews with four of the women who have been diagnosed with endometriosis.</p>
<p>Our research identified the <a href="https://www.tandfonline.com/doi/full/10.1080/10810730.2023.2299003">four main challenges</a> people faced in accessing endometriosis care: </p>
<h2>1. Systemic sexism</h2>
<p>Our participants described a health system tarred by systemic sexism. Experiences were characterised by doctors and nurses not believing them or thinking they were exaggerating. </p>
<p>One participant said: “I have been told that my pain was in my head or that I must have a low pain threshold.” </p>
<p>This led the participants to feel ashamed, embarrassed and powerless – making them less likely to seek out help in the future.</p>
<p>Many also reported feeling their concerns were dismissed as “women’s issues” that shouldn’t be discussed, with one interviewee revealing: </p>
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<p>I have no problem talking about menstruation and periods – but it is people’s and society’s reactions to the topic that makes me feel as though I cannot say anything. Almost as if it is a women’s issue that you must deal with quietly and alone. </p>
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<p>This also extended to their workplace, where some reported not being supported by management even after being diagnosed – and feeling pressure to return to work early after surgery.</p>
<h2>2. Long waiting lists</h2>
<p>Long waiting lists prevented participants from seeking help. And, many felt resigned to pay for private healthcare if they could afford it. Those who couldn’t were left “in the hands of the NHS”.</p>
<p>Nine participants reported paying for private tests or appointments. These participants saw this as the only way to get a diagnosis, with one interviewee revealing:</p>
<blockquote>
<p>When I raised endometriosis as a potential issue I was given the reply ‘I don’t know anything about that condition’ from the GP. Non-specialist gynaecologists also seem to misunderstand the condition and it was only when I recently went for a private consultation that I was believed and was told it’s highly likely that I have the condition.</p>
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<p>Others chose private care because they felt waiting any longer for NHS care would have had a serious impact on their mental health. </p>
<h2>3. Lack of treatment options</h2>
<p>Participants overwhelmingly reported they felt helpless about their treatment options – even after being diagnosed. As one interviewee put it:</p>
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<p>I feel helpless when I try to manage my pain. I feel overwhelmed and I can sit there for a while and just not know what to do. I feel like I have given up trying to manage my pain. I’ve noticed it has become part of my life and I am used to it, to the point where I don’t notice the mild discomfort anymore. I don’t think I even realised that a healthy person doesn’t have this constant pain.</p>
</blockquote>
<p>Others reported this helplessness stemmed from their experiences with healthcare providers. One participant even said her doctor made her feel that “surgery was pointless” – revealing that when she was offered surgery, she was told it would have little effect in managing her pain.</p>
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<img alt="A woman in pain speaks with a female doctor." src="https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572137/original/file-20240130-29-84joju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some of the interviewees spoke of difficulty in getting help from their doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-patient-holding-her-abdomen-pain-2256679083">Drazen Zigic/ Shutterstock</a></span>
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<p>Another participant stated that the “general ‘trial and error’ approach to my treatment made me feel mistrusting of the diagnosis process and subsequent treatment”.</p>
<h2>4. Self doubt and fatigue</h2>
<p>Having symptoms repeatedly dismissed and not believed by doctors led women to mistrust their own experience. They worried that even if they tried getting help, they wouldn’t receive the support they wanted anyway. Women reported intense and overwhelming fear and helplessness, feeling drained from being forced to advocate for themselves.</p>
<p>One woman told us, “I have totally lost faith in my own thoughts and feelings and feel genuinely terrified to try and speak to more doctors.” Another said, “I don’t have it in me to fight and advocate for myself anymore as it’s just so exhausting.” </p>
<h2>Need for change</h2>
<p>Having strong, trusting relationships with doctors is central to having a <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-019-0774-6">positive experience</a> in managing endometriosis and getting the right healthcare. When concerns are repeatedly dismissed, it can cause people with endometriosis to <a href="https://www.tandfonline.com/doi/full/10.1080/10410236.2022.2048468">avoid engaging</a> with the healthcare system altogether. Our research shows that these issues still remain problems today, contributing to delayed diagnosis and poor management of the disease. </p>
<p>Our findings suggest that we need cultural change. We need to de-stigmatise gynaecological health and change attitudes towards pain so that it’s no longer dismissed or normalised. </p>
<p>We also need better awareness of endometriosis and training for doctors and nurses so that diagnoses and treatment happen more quickly.</p>
<p>But until that systemic change happens, many people with endometriosis may still face obstacles in accessing care. If you suspect you have endometriosis, we advise keeping a “pain diary” – documenting when, where and how often your pain is happening so that you can provide your doctor with more detail on your experiences.</p>
<p>If you don’t feel like you’re being taken seriously, ask for a second opinion. There’s also lots of support available from national charities such as <a href="https://www.endometriosis-uk.org/">Endometriosis UK</a>, which can provide information on the condition, and also offer support groups and helplines for those affected.</p><img src="https://counter.theconversation.com/content/220179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Endometriosis affects 10% of women in the UK.Jasmine Hearn, Senior Lecturer in Psychology, Manchester Metropolitan UniversityStella Bullo, Senior Lecturer in Linguistics, Manchester Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2178812023-12-04T19:17:08Z2023-12-04T19:17:08ZEndometriosis: It’s time to change the pattern of pain, stigma and barriers to diagnosis and treatment<figure><img src="https://images.theconversation.com/files/563001/original/file-20231201-29-ehllq0.jpg?ixlib=rb-1.1.0&rect=135%2C45%2C6527%2C4366&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Government of Canada recently announced more than $1.6 million for endometriosis patients and research, the largest single investment in endometriosis care in Canada for the last 20 years.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/endometriosis-its-time-to-change-the-pattern-of-pain-stigma-and-barriers-to-diagnosis-and-treatment" width="100%" height="400"></iframe>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/endometriosis">Endometriosis</a> is a debilitating disease that <a href="https://doi.org/10.1016/j.jogc.2020.05.009">affects an estimated one million Canadians</a>. It involves the overgrowth of tissue similar to endometrium tissue (the tissue that lines the uterus). </p>
<p>For people with endometriosis, this tissue grows excessively, both inside and outside of the uterus, which can cause pelvic pain, extreme menstrual cramping and non-menstrual cramping, as well as chronic fatigue and reduced fertility. </p>
<p>The Government of Canada <a href="https://www.canada.ca/en/health-canada/news/2023/09/government-of-canada-strengthens-access-to-sexual-and-reproductive-services-for-people-living-with-endometriosis.html">recently announced more than $1.6 million</a> for endometriosis patients and research, the largest single investment in endometriosis care in Canada for the last 20 years. This much-needed, long-awaited funding will go far to address the many challenges that endometriosis patients face, including struggling to get a diagnosis in the first place, dismissal of their symptoms, related stigma, and ineffective treatments.</p>
<p>Left untreated, endometriosis can affect the central nervous system, leaving patients at heightened risk of abnormal pain and chronic pain presentation, which too often negatively impacts their overall quality of life.</p>
<p>In fact, endometriosis patients often experience a reduced ability to participate in the activities of everyday life. Yolanda Kirkham, an obstetrician-gynecologist (OBGYN) from the University of Toronto, <a href="https://obgyn.utoronto.ca/news/invisible-disease-endometriosis">has reported that</a> girls and young women are unable to attend school for a few days each month due to their symptoms, while others with the disease frequently miss work due to nausea and vomiting. </p>
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<img alt="A doctor and a young woman patient in a clinic" src="https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most cases of endometriosis are not diagnosed by primary care providers, but by specialists — namely OBGYNs to whom they are referred. Long waiting lists to see specialists can contribute to delayed diagnosis.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The unfortunate outcome for these patients is not just their reduced ability to participate in activities. It also means they experience significant losses in their economic productivity. Researchers have found that the average endometriosis patient in Canada <a href="https://doi.org/10.1016/s1701-2163(16)34986-6">loses around $3,400 in economic productivity per year.</a> </p>
<h2>Delayed diagnosis</h2>
<p>One of the significant challenges faced by people with endometriosis is receiving a diagnosis. Patients experience an average delay of <a href="https://doi.org/10.1016/j.jogc.2019.10.038">5.4 years</a> from the onset of symptoms to diagnosis. The symptoms are similar to other reproductive health issues (such as <a href="https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/">polycystic ovary syndrome</a>) or severe period pain, which can be confusing for non-specialist health-care professionals. </p>
<p>Research with endometriosis patients has shown that most cases of endometriosis are not diagnosed by primary care providers, <a href="https://doi.org/10.1016/j.srhc.2015.11.003">but by specialists</a> — namely OBGYNs to whom they are referred. Taken together with long waiting lists for specialists, the barriers to diagnosis are significant. </p>
<p>Another barrier is that women often have difficulty convincing care providers their pain is real and a cause of concern. In a recent research project, one of us (Sarah Seabrook) examined 70 publicly available accounts of people experiencing endometriosis, including quotes printed in newspapers, as well as from the narratives published by endometriosis not-for-profit <a href="https://endoact.ca/">EndoAct</a>. </p>
<p>Patients described being dismissed, that their pain was “<a href="https://endoact.ca/maureen-2/">just muscle pain</a>,” “<a href="https://endoact.ca/kat/">all women go through this</a>,” and “<a href="https://www.cbc.ca/news/canada/saskatoon/endometriosis-chelsea-fataki-1.4605830">this is the way cycles are for women</a>,” and to live with it.</p>
<p>This dismissal of pain is particularly troublesome because people don’t often share their menstrual experiences and may be unable to differentiate between normal and abnormal menstrual experiences. In an article published by CBC News in 2021, a woman with endometriosis reported that the first few times she had her period, she was hospitalized for severe pain, but because this was her initial experience of menstruation, “<a href="https://www.cbc.ca/news/canada/british-columbia/endometriosis-lacking-research-1.5910342">she thought the pain related to her period was normal</a>.”</p>
<h2>Lack of effective treatments</h2>
<p>Once endometriosis is diagnosed, there are significant barriers to receiving effective treatment. <a href="https://doi.org/10.1016/j.fertnstert.2017.01.003">The first line of treatment is typically hormonal birth control</a>, which does nothing to address the growth of endometrium-like tissue, although for some people it can help with controlling menstrual pain. The same is true of anti-inflammatories and painkillers, which can reduce pain, but do little for the growth of endometrium-like tissue. </p>
<p>When things are more severe, patients might be given surgical options such as tissue excision (removing the entire endometriosis lesion) or ablation (burning off the surface of the endometriosis lesion). However, these procedures are rarely curative — the excess endometrium-like tissue grows back in a lot of cases. As a final resort, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286861/">some patients undergo a hysterectomy</a>. For the most part, endometriosis care is focused on either temporarily reducing pain, or temporarily controlling the growth of tissue. </p>
<p>The lack of effective treatment options is tied to an ongoing failure to understand endometriosis, its underlying causes and effects. Leading <a href="https://doi.org/10.1503/cmaj.220637">Canadian experts</a> have been calling for the improved understanding of endometriosis care and its treatment options, and <a href="https://endoact.ca/wp-content/uploads/2023/04/DiscussionENF2023.pdf">advocates</a> have been mobilizing for increased funding to understand, diagnose and treat endometriosis in Canada. </p>
<p>To improve outcomes, endometriosis patients need more research, more options and more attention to be paid to the disease. The newly announced federal investment in endometriosis research and care by the federal government is a good first step — although continued funding and support will be needed to address the continued, far-reaching effects of endometriosis in Canada.</p>
<p><em>This is a corrected version of a story originally published on Dec. 4, 2023. The earlier story used the term “endometrial tissue” instead of “endometrium-like tissue” or “tissue similar to endometrium tissue.”</em></p><img src="https://counter.theconversation.com/content/217881/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alana Cattapan receives funding from the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Sarah Seabrook does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Endometriosis often means years of severe pain, lost productivity and dismissed symptoms before getting a diagnosis — followed by ineffective treatment. New funding aims to change this pattern.Sarah Seabrook, Research Assistant in the Department of Political Science, University of WaterlooAlana Cattapan, Assistant Professor and Canada Research Chair in the Politics of Reproduction, University of WaterlooLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142102023-11-03T12:43:40Z2023-11-03T12:43:40ZUnderstanding that chronic back pain originates from within the brain could lead to quicker recovery, a new study finds<figure><img src="https://images.theconversation.com/files/551241/original/file-20230929-27-cur5dq.jpg?ixlib=rb-1.1.0&rect=56%2C0%2C6240%2C4100&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approximately 16 million U.S. adults have chronic back pain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/suffering-man-holding-his-back-in-spring-park-royalty-free-image/1490418520?phrase=lower+back+pain&adppopup=true">Olena Ruban/Moment via Getty Images</a></span></figcaption></figure><p>Most people with chronic back pain naturally think their pain is caused by injuries or other problems in the body such as arthritis or bulging disks. But our research team has found that thinking about the root cause of pain as a process that’s occurring in the brain can help promote recovery. That is a key finding of a study my colleagues and I <a href="https://doi.org/10.1001/jamanetworkopen.2023.33846">recently published in JAMA Network Open</a>, a monthly open-access medical journal.</p>
<p>We have been studying a psychological treatment called <a href="https://www.physio-pedia.com/Pain_Reprocessing_Therapy">pain reprocessing therapy</a> that may help “turn off” unhelpful and unnecessary pain signals in the brain. To do this, we carried out a study in which some people were randomly chosen to receive the pain reprocessing therapy treatment, while some got a placebo injection into their backs.</p>
<p>We included 151 adults ages 21 to 70 years old with chronic back pain. We found that 66% of participants reported being pain-free or nearly pain-free after pain reprocessing therapy, compared with 20% of people who received a placebo. </p>
<p>These results were remarkable because previous trials of psychological treatments <a href="https://doi.org/10.1097/j.pain.0000000000002357">rarely led to people reporting full recoveries</a> from chronic pain. So we needed to better understand how this treatment worked: What changed in people’s thinking that helped them recover from chronic back pain? </p>
<h2>Why it matters</h2>
<p>Chronic pain is one of the <a href="https://doi.org/10.15585/mmwr.mm6736a2">biggest health problems today</a>. It is the leading cause of disability in the U.S., and it has <a href="https://doi.org/10.17226/13172">an economic cost greater than that of diabetes or cancer</a>. </p>
<p>The most common chronic pain condition is <a href="https://www.ncbi.nlm.nih.gov/books/NBK538173/">back pain</a>. Many patients – and doctors – are focused on identifying different back problems that they suspect may be causing the pain. So they try all sorts of treatments, <a href="https://doi.org/10.1016/S2665-9913(21)00032-1">often to no avail</a>. </p>
<p>A growing number of scientists now believe that many cases of chronic back pain are <a href="https://doi.org/10.1016/s0140-6736(21)00392-5">caused primarily by brain changes</a>. Pain can originate with an injury, but then the pain system can get “stuck” and keep firing <a href="https://doi.org/10.1093%2Fbrain%2Fawt211">long after injuries have healed</a>. </p>
<p>Pain is the brain’s alarm system, letting us know about injuries or other threats to our body. Much of the time, the system works well, accurately warning us that a part of our body is injured and needs to be protected. But when a person has been in pain for months, years or even decades, pain processing pathways are more likely to fire, and brain regions that typically are not involved in pain start to be involved. Chronic pain also leads to <a href="https://doi.org/10.1038/nri3621">increased levels of activity in glial cells</a>, which are part of the brain’s immune system. All these changes in the brain then serve to “entrench” the pain, making it persist.</p>
<p>People, very understandably, think that if their back hurts, there must be a problem in the back – even though we researchers <a href="https://doi.org/10.3174/ajnr.A4173">know this is often not the case</a>. </p>
<p>It’s critical to note that just because the signal originates in the brain, the pain is not any less real. The pain is always real, no matter what. But to treat it effectively, one needs to accurately identify the root cause. </p>
<h2>How we do our work</h2>
<p>In our study, we asked people to tell us in their own words what they think is the cause of their chronic back pain. It is a simple question, but few studies have asked their participants to describe the source of their pain.</p>
<p>Participants in our study described injuries, weak muscles, arthritis and other bodily factors as the causes of their pain. Almost no one mentioned anything about the mind or brain. </p>
<p>One of the main goals of pain reprocessing therapy is to help people think differently about the causes of their pain. After we treated participants with pain reprocessing therapy, about half the causes of pain that people described were related to the mind or brain. They said things like “anxiety,” “fear” or “neural pathways” were the causes of their pain. </p>
<p>The more that people shifted to this kind of understanding, the more their back pain went down. We think this shift in understanding reduces fear and avoidance of pain, which can tamp down pain pathways in the brain and promote healthy, pain-reducing behaviors like exercise and socializing.</p>
<p>Ask your health providers, or check out <a href="https://centerforinsightmedicine.com/nsq-explanations/">these online resources</a> that can <a href="https://ppdassociation.org/ppd-self-questionnaire">help you assess</a> whether and when the brain is playing a role in chronic pain. </p>
<p>Accurately identifying the underlying causes of pain is the first step toward healing it.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/214210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yoni Ashar consults for Lin Health, Inc., the Pain Reprocessing Therapy Center, and Mental Health Partners of Boulder County. He receives funding from the NIH, VA, and the Psychophysiological Disorders Assocation. </span></em></p>An intriguing therapy that shifts what people perceive as the source of their pain could aid in pain management.Yoni Ashar, Assistant Professor of General Internal Medicine, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2038292023-11-01T12:36:19Z2023-11-01T12:36:19ZEndometriosis afflicts millions of women, but few people feel comfortable talking about it<figure><img src="https://images.theconversation.com/files/555396/original/file-20231023-21-48765g.jpg?ixlib=rb-1.1.0&rect=38%2C0%2C5046%2C3369&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Endometriosis pain can be so severe that it impairs a person's ability to keep up with school, succeed at work or have a satisfying sex life.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/stomach-pain-royalty-free-image/1463546435?phrase=pain&adppopup=true">Kinga Krzeminska/Moment via Getty Images</a></span></figcaption></figure><p><a href="https://www.who.int/news-room/fact-sheets/detail/endometriosis#">Endometriosis</a> causes physical, sexual and emotional pain. About <a href="https://www.ox.ac.uk/news/2023-03-14-global-study-shows-experience-endometriosis-rooted-genetics">190 million people around the globe</a> have endometriosis, <a href="https://gonzalez-colon.house.gov/media/press-releases/house-approves-push-finkenauer-and-endometriosis-caucus-double-research">including one in 10 American women</a>, but there has historically been <a href="https://doi.org/10.1007/s00404-023-07205-3">a deafening silence</a> about the disease and the pervasive impact it can have on a person’s life. </p>
<p>While endometriosis is a chronic gynecological illness that can affect anyone with a uterus – women, transgender men and nonbinary individuals – it often goes undiagnosed because its symptoms can be attributed to other physical or psychological concerns. Patients presenting with this pain are often told it is “all in your head.” </p>
<p>However, endometriosis is becoming a more visible illness, thanks in part to celebrities such as Lena Dunham, Chrissy Teigen, Amy Schumer, Whoopi Goldberg and others who have <a href="https://www.everydayhealth.com/endometriosis/living-with/celebrities-who-speak-endometriosis/">begun sharing their stories publicly</a>. After going undiagnosed for 23 years, Padma Lakshmi, a popular cookbook author, actress and host of the TV show “Top Chef,” founded <a href="https://www.endofound.org/">EndoFund, previously Endometriosis Foundation of America</a>, in 2009 so that others do not have to go through what she did.</p>
<p>I am a <a href="https://www.adler.edu/programs/kristina-s-brown/">couple and family therapy professor, clinician</a> and <a href="https://scholar.google.com/citations?user=ZeuvLPoAAAAJ&hl">researcher</a>. My own endometriosis diagnosis at the age of 19 has inspired my work exploring how this illness affects others beyond the physical symptoms.</p>
<p>To better understand the impact of endometriosis on relationships, I interviewed 10 couples about their experiences of diagnosis, treatment and living with this disease. Through their stories of how endometriosis-related pain can affect every aspect of daily life, including their intimate relationships, I provide some specific recommendations. The quotes I have included in this article <a href="https://surface.syr.edu/mft_etd/14/">are from my doctoral dissertation research</a>. </p>
<h2>The basics of endometriosis</h2>
<p>When a person has endometriosis, the endometrial cells that line their uterus “implant” in places outside the uterus, such as the ovaries, fallopian tubes and the lining of the abdomen — called the <a href="https://teachmeanatomy.info/abdomen/areas/peritoneum/">peritoneum</a>. At the end of each menstrual cycle, the uterus sheds its lining, which exits the body via the cervix and vagina. The “misplanted” endometrial cells also shed, but they have no place to go – resulting in internal bleeding, inflammation and pain. </p>
<p>An endometriosis diagnosis is described in stages related to the visual presence of the disease, from minimal, or Stage 1, to severe, or Stage 4. However, there is no connection between the stage and the experience of pain. </p>
<p>One symptom of endometriosis is <a href="https://doi.org/10.1080/10410236.2018.1440504">intense pain during the menstrual cycle</a>. Another is pain with sex. Because pain with menses or sex can be attributed to “normal” pain, a history of sexual abuse or psychiatric reasons such as a dislike of sex, some people with endometriosis wait an average of seven years for diagnosis, which can <a href="https://doi.org/10.1016/j.advms.2022.02.003">be visually confirmed only through</a> a procedure called <a href="https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/laparoscopy">laparoscopy</a>. </p>
<p>In addition to these and other types of severe pain, endometriosis <a href="https://doi.org/10.1111/jocn.16145">can also cause infertility</a>, and patients who want to have children must often undergo <a href="https://doi.org/10.3389/fsurg.2022.1049119">medical or surgical interventions</a> to conceive.</p>
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<figcaption><span class="caption">Dr. Megan Wasson of the Mayo Clinic explains what endometriosis is and how it can be treated.</span></figcaption>
</figure>
<h2>Impacts on school, work and sex</h2>
<p>Physical pain from endometriosis can be debilitating. Adolescents with endometriosis <a href="https://theconversation.com/endometriosis-can-end-womens-careers-and-stall-their-education-thats-everyones-business-179846">may struggle to keep up</a> with their classes, friends, homework or extracurricular activities when the pain becomes too severe. They may <a href="https://doi.org/10.1016/j.jpag.2021.01.021">shift to home-schooling or virtual learning</a> <a href="https://www.yalemedicine.org/news/teens-endometriosis">to complete their studies</a>.</p>
<p>The pain can also deeply <a href="https://theconversation.com/endometriosis-can-end-womens-careers-and-stall-their-education-thats-everyones-business-179846">affect a career trajectory</a>. “I almost lost my job because of time off,” one interviewee told me. “In fact, when I had to get my hysterectomy, I walked in to tell my manager and he goes, ‘Well, I hope you’re not going to tell me that you have to have a hysterectomy and have to be out for six weeks!’ And I just broke down in tears.” </p>
<p>All of my participants shared experiences where doctors <a href="https://doi.org/10.3390/ijerph20043362">dismissed complaints</a> of sexual pain – called <a href="https://www.mayoclinic.org/diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967">dyspareunia</a> – from endometriosis. This can delay diagnosis and treatment.</p>
<p>Sex and intimacy often become nonexistent, while some couples shared that they have come to accept that <a href="https://hdl.handle.net/2123/22345">pain is part of sex</a>. One woman shared with me: “I don’t want to be touched or have my naked body seen because I feel bloated and ugly and I’m in horrible pain!” </p>
<p>Partners can also be affected emotionally. “I just feel horrible,” one told me. “There are times when we are having sex that I actually feel guilty that I know that I am hurting her and I know she is going to be in pain and it makes me unhappy.”</p>
<p>These experiences of pain, of not being believed by doctors and professionals, of negative effects on education and career and of intimacy destroyed create a heavy emotional burden on individuals and relationships. </p>
<h2>Breaking the silence around endometriosis</h2>
<p>When I was diagnosed with endometriosis, it changed the course of my life. My partner and I learned to expand our definition of intimacy and to redistribute household responsibilities when I was incapacitated. As the risk of infertility only increases without intervention, we started conversations about having children earlier than anticipated. My diagnosis also led me to focus my professional identity as a medical family therapist to help others deal with endometriosis and chronic illnesses.</p>
<p>Based on this experience, here are some ways to break this silence:</p>
<ul>
<li><p>Learn about endometriosis. It directly helps when one’s support systems are educated.</p></li>
<li><p>Separate the person from the disease. When the pain you are experiencing from endometriosis is debilitating, help those around you who are also affected to understand that it is because of your endometriosis and it is not personal. </p></li>
<li><p>Speak from your own experience, saying, “I …” rather than “You …” When we do this, it decreases the other person’s defenses and opens up the communication, making space for connection.</p></li>
</ul>
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<figcaption><span class="caption">Social work researcher Brené Brown describes how to create a genuine empathetic connection with another person.</span></figcaption>
</figure>
<h2>Recommendations from people living it</h2>
<p>My research participants shared their own recommendations with me, especially the importance of <a href="https://doi.org/10.12968/bjon.2005.14.9.18073">believing that their pain is real</a>; accept that what they are sharing is their very real experience, and let them know that they are believed. </p>
<p>Bestselling author and social work researcher <a href="https://www.youtube.com/watch?v=KZBTYViDPlQ&ab_channel=DianaSimonPsihoterapeut">Brené Brown has said</a>, “Empathy fuels connection, sympathy drives disconnection.” Approaching someone with endometriosis from a position of empathy sends a message that you <a href="https://doi.org/10.5301/JE.2011.8906">want to work with them collaboratively</a>. </p>
<p>By practicing these important relationship skills, we can break the silence around endometriosis.</p><img src="https://counter.theconversation.com/content/203829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I continue to be grateful to the ten couples who shared their experiences of painful sex with endometriosis for my dissertation research.</span></em></p>Health care providers often dismiss endometriosis pain as ‘all in your head’ − which can delay a correct diagnosis and treatment for years.Kristina S. Brown, Professor and Chair of Couple and Family Therapy, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158702023-10-27T12:18:30Z2023-10-27T12:18:30ZWhite patients are more likely than Black patients to be given opioid medication for pain in US emergency departments<figure><img src="https://images.theconversation.com/files/556165/original/file-20231026-19-8q0th6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5499%2C3663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have struggled to find the balance between effective pain management and the very real addiction risks that come with prescription pain medication.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?phrase=pain+treatment&adppopup=true">BackyardProduction/iStock via Getty Images Plus</a></span></figcaption></figure><p>White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from <a href="https://doi.org/10.1007/s11606-023-08401-2">our recent study</a>, published in the Journal of General Internal Medicine. We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter. </p>
<p>We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain. Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.</p>
<p>Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.</p>
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<h2>Why it matters</h2>
<p>These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as <a href="https://www.hhs.gov/healthcare/about-the-aca/index.html">the Affordable Care Act</a>, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.</p>
<p>There’s no question that as the <a href="https://www.nytimes.com/2023/02/20/nyregion/sudden-deaths-overdoses-fentanyl-nyc.html">ongoing opioid crisis</a> <a href="https://www.npr.org/2023/08/30/1196343448/fentanyl-deaths-teens-schools-overdose">continues to escalate</a>, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain. </p>
<p>Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a <a href="https://doi.org/10.1111/j.1526-4637.2010.00983.x">greater likelihood of developing long-term pain</a>. There are over <a href="https://doi.org/10.1007/s11606-023-08401-2">40 million pain-related emergency department visits annually</a>, so it is clear that equitable pain treatment is a fundamental component of a fair health care system. </p>
<h2>What still isn’t known</h2>
<p>We do not know why such marked racial disparities exist. Some researchers <a href="https://doi.org/10.1056%2FNEJMsa2034159">have argued</a> that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been <a href="https://doi.org/10.1111/add.15233">lower in Black populations compared with white people</a>. However, this trend has <a href="https://doi.org/10.1111/add.15233">started to change in recent years</a>. </p>
<p>In addition, some evidence suggests that clinicians <a href="https://doi.org/10.1073/pnas.1516047113">may hold unconscious biases</a>, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are <a href="https://doi.org/10.1371/journal.pmed.1001411">less willing to accept pain medication</a>. </p>
<p>While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world. </p>
<h2>What’s next?</h2>
<p>The need for tackling racial disparities in health was brought into focus once more in February 2023, when the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/16/fact-sheet-president-biden-signs-executive-order-to-strengthen-racial-equity-and-support-for-underserved-communities-across-the-federal-government/">Biden-Harris administration</a> signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.</p>
<p>The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.</p><img src="https://counter.theconversation.com/content/215870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Undertreated pain can result in unnecessary suffering and a greater likelihood of long-term chronic pain.Trevor Thompson, Associate Professor of Clinical Research, University of GreenwichSofia Stathi, Professor of Social Psychology, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2117652023-09-19T11:13:49Z2023-09-19T11:13:49ZChronic pelvic pain affects up to 26% of women – our latest research brings us closer to better treating it<figure><img src="https://images.theconversation.com/files/546669/original/file-20230906-20-51oc4q.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6558%2C4290&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lack of understanding about chronic pelvic pain has left women with limited treatment options.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-young-black-girl-suffering-severe-2190845421">Studio Romantic/ Shutterstock</a></span></figcaption></figure><p>Chronic pelvic pain affects between <a href="https://bjgp.org/content/51/468/541.short">5% and 26%</a> of women worldwide. It can be associated with conditions such as endometriosis (where tissue resembling the lining of the womb is found outside the womb) and interstitial cystitis (bladder pain syndrome). Some women also have chronic pelvic pain without a specific cause. </p>
<p>Despite how many women are affected by chronic pelvic pain, we still don’t fully understand the <a href="https://www.frontiersin.org/articles/10.3389/frph.2023.1140857/full">mechanisms underlying it</a>. This has meant that women suffering from chronic pelvic pain have limited treatment options.</p>
<p>There are many reasons why the mechanisms causing chronic pelvic pain remain unknown. One of these is that there’s huge variation in the intensity and type of pain experienced – even in cases where the chronic pain is caused by a specific disease. </p>
<p>For example, some women with endometriosis experience no pelvic pain, others experience severe pain every day and others experience everything in between. The pain experienced also <a href="https://www.nejm.org/doi/10.1056/NEJMra1810764">doesn’t correlate</a> with what endometriosis looks like in the body. </p>
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<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/vulva-health-conditions-its-time-to-shatter-the-silence-210999">Vulva health conditions: it’s time to shatter the silence</a></em></p>
<p><em><a href="https://theconversation.com/birth-trauma-is-a-growing-problem-experiencing-it-myself-revealed-how-few-people-understand-it-209634">Birth trauma is a growing problem — experiencing it myself revealed how few people understand it</a></em></p>
<p><em><a href="https://theconversation.com/uks-first-successful-womb-transplant-key-questions-answered-212115">UK’s first successful womb transplant – key questions answered</a></em></p>
<hr>
<p>There are also many <a href="https://www.sciencedirect.com/science/article/pii/S1521693418300324">different types of pain experienced</a> with chronic pelvic pain – including pain while menstruating, pain during sex and pain when urinating or having a bowel movement. People with chronic pelvic pain may experience any of these and in any combination. </p>
<p>We know from other chronic pain conditions (such as fibromyalgia and diabetic neuropathy) that different mechanisms cause pain depending on the person – and that each of these <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(21)00392-5.pdf">different mechanisms</a> respond differently to <a href="https://bnf.nice.org.uk/treatment-summaries/neuropathic-pain/">treatments</a>. </p>
<p>Research we conducted earlier this year has now shown that chronic pelvic pain operates similarly. Our research showed that the mechanisms that cause chronic pelvic pain seem to <a href="https://journals.lww.com/pain/fulltext/9900/comprehensive_quantitative_sensory_testing_shows.318.asp">vary from person to person</a>.</p>
<h2>Mechanisms of pain</h2>
<p>We conducted our study on 85 women – 59 of whom had chronic pelvic pain. Of those with chronic pelvic pain, 25 had endometriosis, 13 had bladder pain syndrome, 15 had both endometriosis and bladder pain syndrome and six had pain with no specific cause. Participants were from the UK, US and Portugal and were aged between 18 and 50.</p>
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<img alt="A woman sitting in an office chair holds her stomach in pain." src="https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546671/original/file-20230906-15-pa2ahh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Those with chronic pelvic pain had lower pain thresholds to pressure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/long-hair-woman-holding-abdomen-sitting-526393795">Zetar Infinity/ Shutterstock</a></span>
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<p>To understand whether the mechanism causing pelvic pain differed depending on the person, we carried out a series of sensory tests. This involved exposing the participants to various sensations – such as vibration, touch, pressure and temperature. </p>
<p>We also asked participants how these sensations felt to them, and at what point these sensations became painful. This allowed us to look at different types of nerves and how they function. </p>
<p>We also looked at how responses differed between those with chronic pelvic pain and those without pain. Participants were then grouped according to their sensory profiles.</p>
<p>One of the most striking findings was that women with chronic pelvic pain had lower pain thresholds when it came to sensations of pressure on the lower tummy and pelvis compared with the control group. This was particularly true in those with bladder pain. This suggests there’s communication between the pelvic organs and the skin, resulting in more pain.</p>
<p>We also found that some women with chronic pain were less able to detect changes in temperature and touch. This loss in nerve function suggests that for some, chronic pelvic pain may be caused by <a href="https://www.frontiersin.org/articles/10.3389/fpain.2021.743812/full">damage to the nerves</a>.</p>
<p>We then looked at the overall sensory profiles of the chronic pelvic pain group to see which <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515640">chronic pain subgroup</a> they fitted into. We found that around 7% had a “healthy” sensory profile – meaning the way they felt the sensations were as we would expect from healthy people. </p>
<p>Around half of those with chronic pelvic pain were placed in the “<a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(21)00392-5.pdf">mechanical hyperalgesia</a>” subgroup. This meant they had changes in pain processing parts of the brain, which meant the volume of their pain was “turned up” by default.</p>
<h2>Parallels of pain</h2>
<p>This work gives new insight into the complexity of chronic pelvic pain in terms of the mechanisms causing it. It helps us draw parallels with other chronic pain conditions, which may mean we can use research and treatments that have worked for these conditions to pick new targets for treating chronic pelvic pain. </p>
<p>The next steps of this research will be working out what treatments will work for whom depending on their sensory pain profile and the underlying mechanisms causing their pain.</p>
<p>Treatments for chronic pelvic pain have limited effectiveness. For example, studies show <a href="https://pubmed.ncbi.nlm.nih.gov/28668150/">11-19% of women with endometriosis</a> have no reduction in pain, even <a href="https://pubmed.ncbi.nlm.nih.gov/31718952/">after surgery</a>. Based on the findings of our study, a new approach could mean that specific treatments can be chosen instead for each person, depending on the mechanisms causing their pain. This would hopefully be more effective.</p>
<p>Given that chronic pelvic pain is so prevalent in women worldwide and has a huge effect on their <a href="https://pubmed.ncbi.nlm.nih.gov/32532273/">quality of life</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/35926345/">wellbeing</a>, moving towards a more personalised approach to treatment could result in huge improvements for <a href="https://pubmed.ncbi.nlm.nih.gov/33442286/">millions of women</a>.</p><img src="https://counter.theconversation.com/content/211765/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lydia Coxon is affiliated with the Pelvic Pain Support Network.
This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No (777500). This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA.</span></em></p><p class="fine-print"><em><span>Katy Vincent receives research funding from NIHR, UKRI, NIH, IMI-2, and Bayer AG. Her institution has received honoraria for consultancy she has done for Bayer AG, Eli Lilly, AbbVie and Reckitts.</span></em></p>Our research showed that the mechanisms causing chronic pelvic pain vary from person to person.Lydia Coxon, Postdoctoral Research Assistant in Pain Data Collection and Analysis, University of OxfordKaty Vincent, Associate Professor, Pain in Women Group, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2078662023-09-12T11:38:21Z2023-09-12T11:38:21ZWomen’s pain is often not believed – here’s how to make your voice heard when seeking help<figure><img src="https://images.theconversation.com/files/545961/original/file-20230901-29-5qos98.jpg?ixlib=rb-1.1.0&rect=6%2C0%2C4287%2C3495&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One survey found over half of female respondents had had their pain dismissed by a clinician.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/menstrual-pain-sad-arab-woman-hijab-2088577228">Keronn art/ Shutterstock</a></span></figcaption></figure><p>When you go to the doctor, you expect they’ll listen to your concerns and help fix whatever problem you may be experiencing. But <a href="https://theconversation.com/womens-pain-is-routinely-underestimated-and-gender-stereotypes-are-to-blame-new-research-158599">many women</a>, especially those suffering with chronic pain conditions, find the opposite is true. This can make it difficult for women to get the treatment they need.</p>
<p>For instance, researchers who interviewed endometriosis sufferers on their experiences with healthcare practitioners found many struggled to <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/jocn.13872?casa_token=Mp6VZw4Y2fgAAAAA:xndGnnnaNPs9nsEP4xCVPZ6WviGsxp5BWEhgiuy3TZpnA8rDIdLDuugfO2zh6LeGTPpTqKHJ__0WNQE">get the support</a> they needed. As one participant put it, “you need to try so hard that they believe you, because they don’t. You experience that immediately, that they don’t believe you.”</p>
<p>In the UK, a survey by the Wellbeing of Women charity (which invests in research on women’s health) found that over <a href="https://www.wellbeingofwomen.org.uk/news/over-half-of-uk-women-feel-their-pain-is-ignored-or-dismissed-new-report-shows">half of female respondents</a> felt their pain had been dismissed or ignored by a healthcare professional at some point. Women in other parts of the world – including North America, Australia and <a href="https://journals.sagepub.com/doi/full/10.1177/1403494820987466">Europe</a> – report <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845507/">similar experiences</a>. </p>
<p>There’s a clear <a href="https://journals.sagepub.com/doi/full/10.1177/1403494820987466">gender gap</a> when it comes to identifying and treating women’s pain compared to men’s. For instance, women are less likely than men to <a href="https://pubmed.ncbi.nlm.nih.gov/29682130/">have positive treatment outcomes</a> for chronic conditions such as angina and musculoskeletal pain.</p>
<p>Physicians are <a href="https://pubmed.ncbi.nlm.nih.gov/18332383/">four times more likely</a> to recommend a knee replacement for a man than a woman with the same knee injury. The poorer quality care women received compared to men after suffering a heart attack was to blame for <a href="https://heart.bmj.com/content/105/7/516">8,243 preventable deaths</a> between 2003-2013 in England and Wales.</p>
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<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/women-still-feel-like-they-arent-listened-to-when-they-give-birth-heres-what-could-help-change-things-206815">Women still feel like they aren’t listened to when they give birth – here’s what could help change things</a></em></p>
<p><em><a href="https://theconversation.com/birth-trauma-is-a-growing-problem-experiencing-it-myself-revealed-how-few-people-understand-it-209634">Birth trauma is a growing problem — experiencing it myself revealed how few people understand it</a></em></p>
<p><em><a href="https://theconversation.com/science-experiments-traditionally-only-used-male-mice-heres-why-thats-a-problem-for-womens-health-205963">Science experiments traditionally only used male mice – here’s why that’s a problem for women’s health</a></em></p>
<hr>
<p>The dismissal of women’s pain also leads to long delays in diagnoses and treatment for conditions such as <a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">polycystic ovary syndrome (PCOS)</a> and <a href="https://theconversation.com/endometriosis-three-reasons-care-still-hasnt-improved-157457">endometriosis</a>. </p>
<p>The gender pain gap affects not only adults, but <a href="https://academic.oup.com/jpepsy/article/44/4/403/5273626?login=false">children</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/29110522/">young people</a> – with research showing young women are more likely to have their <a href="https://pubmed.ncbi.nlm.nih.gov/29110522/">pain dismissed</a> by physicians than young men.</p>
<p>The gender pain gap is even worse for <a href="https://theconversation.com/endometriosis-black-women-continue-to-receive-poorer-care-for-the-condition-200663#:%7E:text=In%20the%20US%2C%20almost%2072,more%20common%20in%20white%20patients.">black women</a>, who are more likely than white women to have their pain dismissed and receive <a href="https://www.pnas.org/doi/full/10.1073/pnas.1516047113">poorer pain treatment</a>.</p>
<p>There also remains <a href="https://www.frontiersin.org/research-topics/25413/pain-in-the-transgender-individual">little research</a> on pain treatment for gender diverse, transgender, non-binary and intersex patients which may mean these groups are even worse off when accessing treatment.</p>
<h2>Gender pain gap</h2>
<p>Pervasive <a href="https://theconversation.com/womens-pain-is-routinely-underestimated-and-gender-stereotypes-are-to-blame-new-research-158599">gender stereotypes</a> are a key reason women’s pain is underestimated. These widely held stereotypes – held even by <a href="https://www.jpain.org/article/S1526-5900(21)00035-3/fulltext">healthcare professionals</a> – construct men as “stoic” and women as “<a href="https://philpapers.org/rec/BENPAG">emotionally expressive</a>” when in pain. </p>
<p>Men are thought to be less likely to seek care for pain – so when they do, they are to be believed. In actuality, this is false, with <a href="https://pubmed.ncbi.nlm.nih.gov/10387413/">research showing</a> men are equally likely to go to the doctor when <a href="https://pubmed.ncbi.nlm.nih.gov/10387413/">experiencing pain</a> as women are.</p>
<p>Women are also believed to have a <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=383803">greater capacity to cope</a> with pain because of the pain that accompanies menstruation and childbirth. These stereotypes mean <a href="https://pubmed.ncbi.nlm.nih.gov/33684539/">women’s pain</a> is viewed as “natural” and “normal” – and may not be taken as seriously by a practitioner.</p>
<figure class="align-center ">
<img alt="An older male doctor speaks with a young female patient." src="https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Even doctors may believe these stereotypes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/experienced-senior-doctor-modern-clinic-talking-2101295176">Studio Romantic/ Shutterstock</a></span>
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<p>One study, which had healthcare professionals watch videos of female and male patients experiencing chronic shoulder pain, found practitioners were more likely to <a href="https://www.jpain.org/article/S1526-5900(21)00035-3/fulltext">underestimate women’s pain</a>. They also reported the women, but not the men, would benefit from psychotherapy. </p>
<p><a href="https://www.independent.co.uk/life-style/health-and-families/health-news/how-sexist-stereotypes-mean-doctors-ignore-women-s-pain-a7157931.html">Other studies</a> have shown healthcare practitioners are sometimes more likely to prescribe sedatives than pain medication to female patients experiencing pain.</p>
<p><a href="https://www.bmj.com/content/381/bmj.p1303">Historically</a>, women have been underrepresented in medical research and clinical trials. In the UK, only from 2024 will it be compulsory for new GPs to have <a href="https://www.gov.uk/government/news/first-womens-health-strategy-for-england-to-tackle-gender-health-gap">training in women’s health</a>. </p>
<p>This may somewhat explain the lack of knowledge practitioners have had in regards to women’s pain and their health concerns. And, women may be given medications and treatments that have only been trialled with men – despite female patients being more likely to experience <a href="https://www.bmj.com/content/381/bmj.p1303.full">side effects</a> from new medications. </p>
<p>The gender pain gap cannot be addressed until disparities in <a href="https://www.bmj.com/content/381/bmj.p1303.full">medical research and funding</a> are. Conditions which have a disproportional affect on women (such as migraines and endometriosis) receive “<a href="https://www.nature.com/immersive/d41586-023-01475-2/index.html">much less</a>” funding relative to their severity and prevalence, while conditions which predominantly affect men (such as HIV) receive <a href="https://www.nature.com/immersive/d41586-023-01475-2/index.html">more funding</a> – despite their lower prevalence.</p>
<h2>Getting the right care</h2>
<p>Pain is never something you should accept and put up with. If you need to speak with a practitioner about your pain, there are many things you can do to ensure your voice is heard.</p>
<p>For example, telling your practitioner how pain affects your <a href="https://theconversation.com/endometriosis-understanding-how-sufferers-describe-pain-could-lead-to-faster-diagnosis-172073">ability to function</a> in your day-to-day can be more effective than trying to rate pain on a scale. Using an <a href="https://www.healthline.com/health/how-to-advocate-for-pain-management">app or diary to track pain</a> and related symptoms, and bringing it with you in the consultation room, can also be helpful. </p>
<p>If you’re comfortable, raise the <a href="https://www.healthline.com/health/how-to-advocate-for-pain-management#advocate-against-bias">issue of bias in pain care</a>. Ask how your practitioner is ensuring you’re not part of the larger statistic of women feeling dismissed. Ask them to explain their diagnostic decision-making and how they’ve ruled out certain conditions. You can also ask them to note in your file why they haven’t made a referral for specialist care. This may be helpful if you return with the same symptoms later. </p>
<p>Bring a family member or friend to advocate for you if you don’t feel comfortable doing it alone. In the UK, you can also ask for a <a href="https://www.nhs.uk/conditions/social-care-and-support-guide/help-from-social-services-and-charities/someone-to-speak-up-for-you-advocate/">patient advocate</a>, who will speak up for you and help you get the right care.</p>
<p>Addressing <a href="https://www.nihr.ac.uk/blog/improving-womens-health-and-care-through-research/3287">inadequate funding</a> for conditions that affect women, <a href="https://www.elle.com/uk/life-and-culture/culture/a40662488/womens-pain-government-strategy/">improving training</a> for practitioners and <a href="https://www.theguardian.com/see-my-pain/2023/may/26/it-hadnt-all-been-in-my-head-the-truth-about-the-gender-pain-gap#:%7E:text=Despite%20significant%20healthcare%20advances%20in,and%20truly%20alive%20in%202023.">increased awareness</a> of the gender pain gap, will all help ensure women in pain are no longer dismissed.</p><img src="https://counter.theconversation.com/content/207866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annalise Weckesser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women are less likely than men to have positive treatment outcomes for chronic conditions.Annalise Weckesser, Reader in Medical Anthropology, Birmingham City UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2070092023-09-07T20:01:43Z2023-09-07T20:01:43ZWhat is cognitive functional therapy? How can it reduce low back pain and get you moving?<figure><img src="https://images.theconversation.com/files/533074/original/file-20230621-25-swu29c.jpg?ixlib=rb-1.1.0&rect=8%2C186%2C5414%2C3430&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/man-watering-his-plants-7658808/">Pexels/Kampus Production</a></span></figcaption></figure><p>If you haven’t had lower back pain, it’s likely you know someone who has. It affects <a href="https://pubmed.ncbi.nlm.nih.gov/22231424/">around 40% of adults</a> in any year, ranging from adolescents to those in later life. While most people recover, <a href="https://pubmed.ncbi.nlm.nih.gov/29112007/">around 20%</a> go on to develop chronic low back pain (lasting more than three months).</p>
<p>There is a <a href="https://bjsm.bmj.com/content/54/12/698">common view</a> that chronic low back pain is caused by permanent tissue damage including “wear and tear”, disc degeneration, disc bulges and arthritis of the spine. This “damage” is often described as resulting from injury and loading of the spine (such as bending and lifting), ageing, poor posture and weak “core” muscles. </p>
<p>We’re often told to “protect” our back by sitting tall, bracing the core, keeping a straight back when bending and lifting, and avoiding movement and activities that are painful. Health practitioners often <a href="https://theconversation.com/having-good-posture-doesnt-prevent-back-pain-and-bad-posture-doesnt-cause-it-183732">promote and reinforce these messages</a>.</p>
<p>But this is <a href="https://bjsm.bmj.com/content/54/12/698">not based on evidence</a>. An emerging treatment known as <a href="https://pubmed.ncbi.nlm.nih.gov/29669082/">cognitive functional therapy</a> aims to help patients undo some of these unhelpful and restrictive practices, and learn to trust and move their body again. </p>
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Read more:
<a href="https://theconversation.com/having-good-posture-doesnt-prevent-back-pain-and-bad-posture-doesnt-cause-it-183732">Having ‘good’ posture doesn't prevent back pain, and 'bad' posture doesn't cause it</a>
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<h2>People are often given the wrong advice</h2>
<p>People with chronic back pain are often referred for imaging scans to detect things like disc degeneration, disc bulges and arthritis. </p>
<p>But these findings are very common in people <em>without</em> low back pain and research shows they <a href="https://pubmed.ncbi.nlm.nih.gov/24276945/">don’t accurately predict</a> a person’s current or future experience of pain. </p>
<p>Once serious causes of back pain have been ruled out (such as cancer, infection, fracture and nerve compression), there is <a href="https://pubmed.ncbi.nlm.nih.gov/27745712/">little evidence</a> scan findings help guide or improve the care for people with chronic low back pain. </p>
<p>In fact, scanning people and telling them they have arthritis and disc degeneration can <a href="https://pubmed.ncbi.nlm.nih.gov/33748882/">frighten them</a>, resulting in them avoiding activity, worsening their pain and distress.</p>
<p>It can also lead to potentially harmful treatments such as <a href="https://pubmed.ncbi.nlm.nih.gov/27213267/">opioid</a> pain medications, and invasive treatments such as spine <a href="https://pubmed.ncbi.nlm.nih.gov/19127161/">injections</a>, spine <a href="https://pubmed.ncbi.nlm.nih.gov/12709856/">surgery</a> and battery-powered electrical stimulation of spinal nerves. </p>
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Read more:
<a href="https://theconversation.com/opioids-dont-relieve-acute-low-back-or-neck-pain-and-can-result-in-worse-pain-new-study-finds-203244">Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds</a>
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<h2>So how should low back pain be treated?</h2>
<p>A complex range of factors <a href="https://pubmed.ncbi.nlm.nih.gov/29112007/">typically contribute</a> to a person developing chronic low back pain. This includes over-protecting the back by avoiding movement and activity, the belief that pain is related to damage, and negative emotions such as pain-related fear and anxiety. </p>
<p>Addressing these factors in an individualised way is <a href="https://pubmed.ncbi.nlm.nih.gov/29573871/">now considered</a> best practice.</p>
<figure class="align-center ">
<img alt="Physio touches woman's back" src="https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Treatment for back pain needs to be individualised.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/physiotherapist-touching-womans-back-5793653/">Pexels/Yan Krukau</a></span>
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<p><a href="https://pubmed.ncbi.nlm.nih.gov/15936976/">Best practice care</a> also needs to be person-centred. People suffering from chronic low back pain want to be heard and validated. They <a href="https://pubmed.ncbi.nlm.nih.gov/35384928/">want</a> to understand why they have pain in simple language. </p>
<p>They want care that considers their preferences and gives a safe and affordable pathway to pain relief, restoring function and getting back to their usual physical, social and work-related activities.</p>
<p>An example of this type of care is cognitive functional therapy.</p>
<h2>What is cognitive functional therapy?</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/29669082/">Cognitive functional therapy</a> is about putting the person in the drivers’ seat of their back care, while the clinician takes the time to guide them to develop the skills needed to do this. It’s led by physiotherapists and can be used once serious causes of back pain have been ruled out. </p>
<p>The therapy helps the person understand the unique contributing factors related to their condition, and that pain is usually not an accurate sign of damage. It guides patients to relearn how to move and build confidence in their back, without over-protecting it. </p>
<p>It also addresses other factors such as sleep, relaxation, work restrictions and engaging in physical activity based on the <a href="https://www.restorebackpain.com/patient-journey">person’s preferences</a>.</p>
<p>Cognitive functional therapy usually involves longer physiotherapy sessions than usual (60 minutes initially and 30-45 minute follow-ups) with up to seven to eight sessions over three months and booster sessions when required.</p>
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Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
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<h2>What’s the evidence for this type of therapy?</h2>
<p>Our recent clinical trial of cognitive functional therapy, published in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00441-5/fulltext">The Lancet</a>, included 492 people with chronic low back pain. The participants had pain for an average of four years and had tried many other treatments. </p>
<p>We first trained 18 physiotherapists to competently deliver cognitive functional therapy across Perth and Sydney over six months. We compared the therapy to the patient’s “usual care”.</p>
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<img alt="Woman lays in bed, comfortable" src="https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Participants in our study had low back pain for years and tried many other treatments.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/photo-young-woman-lying-bed-night-2142343367">Shutterstock</a></span>
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<p>We found large and sustained improvements in function and reductions in pain intensity levels for people who underwent the therapy, compared with those receiving usual care. </p>
<p>The effects remained at 12 months, which is unusual in low back pain trials. The effects of most recommended interventions such as exercise or psychological therapies are <a href="https://pubmed.ncbi.nlm.nih.gov/34580864/">modest in size</a> and tend to be of <a href="https://pubmed.ncbi.nlm.nih.gov/32794606/">short duration</a>.</p>
<p>People who underwent cognitive functional therapy were also more confident, less fearful and had a more positive mindset about their back pain at 12 months. They also liked it, with 80% of participants satisfied or highly satisfied with the treatment, compared with 19% in the usual care group.</p>
<p>The treatment was as safe as usual care and was also cost-effective. It saved more than A$5,000 per person over a year, largely due to increased participation at work. </p>
<h2>What does this mean for you?</h2>
<p>This trial shows there are safe, relatively cheap and effective treatments options for people living with chronic pain, even if you’ve tried other treatments without success. </p>
<p><a href="https://www.restorebackpain.com/cft-clinicians">Access to clinicians</a> trained in cognitive functional therapy is currently limited but will expand as training is scaled up.</p>
<p>The costs depend on how many sessions you have. Our studies show some people improve a lot within two to three sessions, but most people had seven to eight sessions, which would cost around A$1,000 (aside from any Medicare or private health insurance rebates). </p>
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Read more:
<a href="https://theconversation.com/why-does-my-back-get-so-sore-when-im-sick-the-connection-between-immunity-and-pain-207222">Why does my back get so sore when I'm sick? The connection between immunity and pain</a>
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<img src="https://counter.theconversation.com/content/207009/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter O'Sullivan is a Director and consults at bodylogic.physio. He receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>JP Caneiro is a Director and consults at bodylogic.physio. He has received funding from the National Health and Medical Research Council.</span></em></p><p class="fine-print"><em><span>Mark Hancock received NHMRC funding for grants paid to his university, including for the RESTORE study of cognitive functional therapy.</span></em></p><p class="fine-print"><em><span>Peter Kent's employing institution (Curtin University) received funding from Australian National Health and Medical Research Council (grant number 1145271) for the clinical trial mentioned in this article.</span></em></p>A new therapy aims to undo some of the harmful and restrictive patterns patients have been taught to ‘protect’ their back from pain. Instead, they’re learning to trust and move their body again.Peter O'Sullivan, Professor of Musculoskeletal Physiotherapy, Curtin UniversityJP Caneiro, Research Fellow in physiotherapy, Curtin UniversityMark Hancock, Professor of Physiotherapy, Macquarie UniversityPeter Kent, Adjunct Associate Professor of Physiotherapy, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2108102023-08-07T20:01:51Z2023-08-07T20:01:51ZPictures of pain: how a visual chatbot can help people with chronic pain<p>Chronic or persistent pain is the main reason people seek medical care in Australia. Yet, most chronic pain is incurable and relies on education, exercise and other interventions for management, making it a <a href="https://www.deloitte.com/au/en/services/economics/analysis/cost-pain-australia.html">complex, common and expensive health challenge</a>.</p>
<p>The challenge is more pronounced in the treatment of children and people with diverse needs, such as those with language deficits and varying learning abilities. </p>
<p>Our team of researchers from <a href="http://aehrc.csiro.au">CSIRO</a>, <a href="https://recover.centre.uq.edu.au/">RECOVER Injury Research Centre</a>, the <a href="https://metronorth.health.qld.gov.au/rbwh/healthcare-services/persistent-pain">Tess Cramond Pain and Research Centre</a> and the <a href="https://www.childrens.health.qld.gov.au/service-queensland-interdisciplinary-paediatric-persistent-pain/">Queensland Interdisciplinary Paediatric Pain Service</a> are exploring how therapeutic chatbots can help improve communication between people with chronic pain and health professionals.</p>
<p>To do this, we built a chatbot called <a href="https://twitter.com/RecoverResearch/status/1394776246525960195">Dolores</a>, with a unique feature: a canvas for users to describe their pain with drawings, sketches and doodles. We found that in this case, a picture truly is worth a thousand words. </p>
<h2>About Dolores</h2>
<p>Dolores’s main function is to help users report data on their own pain and provide personalised education. This can be used to enhance communication between users and health professionals and improve pain management.</p>
<p>Dolores is designed to prompt the user for more information, ask follow-up questions, and generally lead the conversation. </p>
<p>The chatbot tailors its responses to the user. It will respond to children with short answers and a limited vocabulary, and responses will gradually increase in complexity with the user’s age.</p>
<p>As the app often captures sensitive data, it was designed with privacy and ethical considerations in mind.</p>
<p>The technology behind Dolores is very different from the large language models behind chatbots such as <a href="https://theconversation.com/chatgpt-isnt-the-death-of-homework-just-an-opportunity-for-schools-to-do-things-differently-205053">ChatGPT</a>. It works from a knowledge base and conversation flow built by occupational, speech and physio therapists, based on diverse experience with clients of different ages. </p>
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Read more:
<a href="https://theconversation.com/aristotle-and-the-chatbot-how-ancient-rules-of-logic-could-make-artificial-intelligence-more-human-142811">Aristotle and the chatbot: how ancient rules of logic could make artificial intelligence more human</a>
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<p>Dolores’s “brain” was built with help from hackathons and industry experts to ensure its responses are always focused on meeting the needs of users. Importantly, it will not give incorrect information or “hallucinate” responses.</p>
<h2>Pain history</h2>
<p>One thing Dolores is used for is to administer what is called a “pain history interview”. </p>
<p>In this process, Dolores asks questions about the onset, location and duration of the user’s pain. It also asks about the sensations and emotions associated with the pain and its impact on daily life, as well as the user’s understanding of pain and their perceptions of different kinds of treatment.</p>
<p>The user can respond to Dolores by talking, typing or drawing. Dolores then produces a transcript which the user can choose to share with their medical professional. </p>
<p>The transcript below was generated using speech recognition from a conversation with an individual living with chronic pain.</p>
<blockquote>
<p><strong>Dolores</strong>: Could you describe or draw what your pain physically feels like?</p>
<p><strong>Client</strong>: Sometimes it’s different … it’s not all the same … then all the days it’s burning tingling </p>
<p><strong>Dolores</strong>: Could you tell me or draw how your pain makes you feel? Physically and mentally.</p>
<p><strong>Client</strong>: Shit makes me feel like shit </p>
<p><strong>Dolores</strong>: And how long have you been in pain for?</p>
<p><strong>Client</strong>: Since I was about 15 years old</p>
<p><strong>Dolores</strong>: Can you tell me or draw how your pain began?</p>
<p><strong>Client</strong>: I am not sure it just began</p>
<p><strong>Dolores</strong>: And how does your pain affect your day-to-day life?</p>
<p><strong>Client</strong>: It affects everything even down to driving, shopping, taking my kids to school. Even just making a cup of tea</p>
<p><strong>Dolores</strong>: What do you believe is the cause of your pain?</p>
<p><strong>Client</strong>: Autoimmune disease and follow on disorders from that</p>
<p><strong>Dolores</strong>: What do you believe are the best treatments for managing your pain?</p>
<p><strong>Client</strong>: Nothing really helps it’s just a matter of learning to deal with it and manage it</p>
</blockquote>
<p>While this example was verbal and detailed, some users – particularly children and adolescents – preferred to doodle. For example, a volcano erupting symbolised a pain flare-up; lightning strikes symbolised sharp, sudden pain; and swirls and waves symbolised cyclic pain. </p>
<p>When asking about the impact of pain on daily life, we received an abundance of stick figures and faces depicting sorrow and loss of identity. </p>
<h2>The future</h2>
<p>In its present state, Dolores can interpret the colours used in a drawing, but not the drawing itself. <a href="https://pubmed.ncbi.nlm.nih.gov/25822055/">Research</a> shows red and black, for example, are commonly used when “painting pain”.</p>
<p>So when soliciting more information about a doodle, Dolores might say things like “That’s a lot of red. What is it?” </p>
<p>The next version of Dolores will have sketch recognition, which we believe will give her more insight and provide extended engagement with clients. </p>
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Read more:
<a href="https://theconversation.com/introducing-edna-the-chatbot-trained-to-help-patients-make-a-difficult-medical-decision-150847">Introducing Edna: the chatbot trained to help patients make a difficult medical decision</a>
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<p>Dolores was received positively in cohorts of patients across different age groups. It will soon be used in the broader chronic pain intervention platform, <a href="https://recover.centre.uq.edu.au/pain-roadmap-mobile-app-help-people-chronic-pain">Pain ROADMAP</a>. </p>
<p>Dolores is a step forward in catering for clients and communities whose language may differ from the clinician and for children and individuals with language disorders, who often have <a href="https://www.spectrumnews.org/news/autistic-children-disproportionately-affected-by-chronic-pain/">higher rates of chronic pain</a> and have difficulties communicating about their pain. </p>
<p>We believe a chatbot that identifies and conveys the symbols of pain to a clinician can be an effective tool for enhanced communication, leading to more effective pain management.</p><img src="https://counter.theconversation.com/content/210810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Andrews is affiliated with RECOVER Injury Research Centre, The University of Queensland and the Tess Cramond Pain and Research Centre, Metro North Hospital and Health Service.</span></em></p><p class="fine-print"><em><span>David Ireland does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A chatbot that lets users express their feelings by drawing may help communication and treatment for people with chronic pain.David Ireland, Senior Research Scientist at the Australian E-Health Research Centre, CSIRONicole Emma Andrews, Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2059102023-05-22T15:12:55Z2023-05-22T15:12:55ZChronic pain can be objectively measured using brain signals – new research<figure><img src="https://images.theconversation.com/files/527287/original/file-20230519-19-eir5ap.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2040%2C1465&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers are working on untangling the neural circuitry of chronic and acute pain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/migraine-conceptual-illustration-royalty-free-illustration/1161025033">Victor Habbick Visions/Science Photo Library via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Using a <a href="https://doi.org/10.1109/TNSRE.2012.2183617">brain implant</a> that can record neural signals over many months, my <a href="https://shirvalkarlab.ucsf.edu">research team</a> <a href="https://scholar.google.com/citations?user=yE7ikcUAAAAJ&hl=en">and I</a> have discovered <a href="https://www.nature.com/articles/s41593-023-01338-z">objective biomarkers of chronic pain severity</a> in four patients with chronic pain as they went about their daily lives.</p>
<p>Pain is one of the most <a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">important and basic subjective experiences</a> a person can have. While there is plenty of evidence that perception of pain <a href="https://www.arthritis.org/health-wellness/healthy-living/managing-pain/understanding-pain/pain-brain-connection">takes place in the brain</a>, there is also a major knowledge gap regarding where and how pain signals are processed in the brain. Even though pain is universal, there has not been a way to objectively measure its intensity. </p>
<p>Most prior studies on the brain signals responsible for pain have relied on <a href="http://dx.doi.org/10.1056/NEJMoa1204471">laboratory experiments in artificial environments</a>. Until now, most research on chronic pain has used indirect measures of brain activity such as <a href="https://www.radiologyinfo.org/en/info/fmribrain">functional magnetic resonance imaging</a> or <a href="https://www.youtube.com/watch?v=tZcKT4l_JZk">electroencephalography</a>. Furthermore, although doctors widely recognize that chronic pain is not just an extension of acute pain – like stubbing your toe – it remains unknown how the brain circuits behind acute and chronic pain relate to each other.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person sitting on couch, holding head in hands." src="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chronic pain can be debilitating.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/african-american-woman-holds-head-in-hands-on-couch-royalty-free-image/1208951217">Catherine McQueen/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Our study was part of a <a href="https://clinicaltrials.gov/ct2/show/NCT03029884">larger clinical trial</a> aimed at developing a new brain stimulation therapy to treat severe chronic pain. My team surgically implanted electrodes in the brains of four patients with post-stroke pain and <a href="https://www.ncbi.nlm.nih.gov/books/NBK448188/">phantom limb pain</a> to record neural signals in their <a href="https://doi.org/10.1016/j.pneurobio.2004.03.006">orbitofrontal cortex</a>, an area of the brain associated with planning and expectation, and <a href="http://doi.org/10.3171/jns.1962.19.2.0089">cingulate cortex</a>, an area associated with emotion.</p>
<p>We asked the patients about their pain severity levels several times a day for up to six months. We then built machine learning models to try to match and predict each patient’s self-reported pain intensity scores with snapshots of their brain activity signals. These brain signals consisted of electrical waves that could be decomposed into different frequencies, similar to how a <a href="https://doi.org/10.5642/jhummath.201401.05">musical chord can be broken down</a> into individual sounds of different pitches. From these models, we found that <a href="https://www.nature.com/articles/s41593-023-01338-z">low frequencies in the orbitofrontal cortex</a> corresponded with each of the patients’ subjective pain intensities, providing an objective measure of chronic pain. The larger the shift in low-frequency activity we measured, the more likely the patient was experiencing intense pain.</p>
<p>Next, we wanted to compare the relationship between chronic pain and acute pain. We examined how the brain responded to short-term, intense pain caused by applying heat to the patients’ bodies. Based on data from two participants, we found that the anterior cingulate cortex was more involved in <a href="https://www.nature.com/articles/s41593-023-01338-z">processing acute pain</a> than chronic pain. This experiment provides the first direct evidence that chronic pain involves information-processing areas of brain distinct from those involved in acute pain.</p>
<h2>Why it matters</h2>
<p>Chronic pain, defined as pain lasting more than three months, affects <a href="https://doi.org/10.1001/jamanetworkopen.2023.13563">up to 1 in 5 people in the U.S.</a> In 2019, the incidence of chronic pain was more common than that of diabetes, high blood pressure or depression. </p>
<p>Neuropathic pain resulting from damage to the nervous system, such as stroke and phantom limb pain, often doesn’t respond to available treatments and can significantly impair physical and emotional function and quality of life. Better understanding how to measure brain activity to track pain could improve the diagnosis of chronic pain conditions and help develop new treatments such as <a href="https://doi.org/10.3389/fncom.2018.00018">deep brain stimulation</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/XCY8uQr2LKo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Deep brain stimulation has been used to treat severe depression.</span></figcaption>
</figure>
<h2>What still isn’t known</h2>
<p>Although our study provides a proof of concept that signals from specific brain regions can serve as an objective measure of chronic pain, it is more likely that pain signals are <a href="http://doi.org/DOI:%2010.1038/srep34853">distributed over a wide brain network</a>. </p>
<p>We still don’t know what other brain regions may harbor important pain signals that may more accurately reflect subjective pain. It is also unclear whether the signals we found would apply to patients with other pain conditions.</p>
<h2>What’s next</h2>
<p>We hope to use these newly discovered neural biomarkers to develop <a href="https://theconversation.com/brain-stimulation-can-rewire-and-heal-damaged-neural-connections-but-it-isnt-clear-how-research-suggests-personalization-may-be-key-to-more-effective-therapies-182491">personalized brain stimulation</a> as a way to treat chronic pain disorders. This approach involves incorporating signals into tailored algorithms that would govern the timing and location of brain stimulation on demand, similar to how a thermostat operates.</p><img src="https://counter.theconversation.com/content/205910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prasad Shirvalkar receives funding from the National Institutes of Health BRAIN Initiative and HEAL Initiative, UCSF Weill Neurosciences Institute, and the George and Judy Marcus Fund. He is leading clinical trials for which Medtronic Inc. has donated devices but no direct funding.</span></em></p>Pain has long been subjectively measured, leading to frustrations for patients and doctors alike. Identifying neural biomarkers of pain could improve diagnosis and lead to better treatments of chronic pain conditions.Prasad Shirvalkar, Associate Professor of Anesthesia, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2023462023-04-20T23:20:21Z2023-04-20T23:20:21ZWhat are dead hangs? What are the shoulder pain risks and how do I do them safely?<figure><img src="https://images.theconversation.com/files/520408/original/file-20230412-26-w7zknd.jpg?ixlib=rb-1.1.0&rect=0%2C24%2C5384%2C2478&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>You might have seen media articles or fitness influencers online urging people to do “dead hangs”, where one hangs loosely from a bar – usually with feet off the floor. The goal is usually to improve upper-body strength and shoulder stability, or stretch out muscles around the shoulder. </p>
<p>But what does the science say? Are dead hangs good for shoulder health?</p>
<p>As with so many things health and fitness, it’s not an easy “yes” or “no”. It really depends on your reason for doing it, your individual biology, and how you do them. For some, dead hangs may risk musculoskeletal injury. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&rect=0%2C41%2C7008%2C4616&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&rect=0%2C41%2C7008%2C4616&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520405/original/file-20230412-14-evx9jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">For some, dead hangs may risk musculoskeletal injury.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>The shoulder: a relatively unstable joint</h2>
<p>Dead hangs <a href="https://sciendo.com/article/10.2478/hukin-2018-0057">may</a> improve grip strength and endurance in rock climbers. This suggests that if you’re well adapted to this type of exercise and have very good upper-body strength, dead hangs may bring hand and forearm benefits.</p>
<p>But while dead hangs may be OK for people with good upper-body strength and no shoulder problems, they can be risky for others. People with shoulder hypermobility (excessive motion of the shoulder) or shoulder instability (such as those who easily dislocate their shoulder) may need to be cautious.</p>
<p>The shoulder, by design, is a relatively unstable joint. It has a large ball-type bone called a humerus, which sits in a relatively small socket called a glenoid.</p>
<p>The passive (non-muscle) tissue around these bones (the capsule, labrum and ligaments) creates a generous space around the shoulder joint – all so you can move your arm though a large range of motion. </p>
<p>Because there’s not much passive support in the shoulder, it relies heavily on active muscle coordination and strength to keep it stable.</p>
<p>The coordination of muscles around the shoulder blade help keep the socket in the right place, and the rotator cuff and deltoid muscles help to control the “ball” in the centre of the socket as you move. </p>
<p>All this means dead hangs, if not done correctly, could present a risk for people with hypermobility in their shoulders.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520403/original/file-20230412-14-78wq4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The shoulder, by design, is a relatively unstable joint.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Hypermobility and the shoulder</h2>
<p>Some people have excessive motion of their joints due to increased elasticity of joint tissue. This is called hypermobility and may be in the shoulder or all joints. </p>
<p>The overhead arm position of a complete dead hang puts you in a position where, inside your shoulder, the ball is pulled away from the socket. Hanging your entire body weight can, in hypermobile people, cause the tissue to stretch even more.</p>
<p>People with shoulder hypermobility are more <a href="https://www.mdpi.com/2077-0383/11/17/5140">likely</a> to develop painful shoulder <a href="https://pubmed.ncbi.nlm.nih.gov/1864037/">instability</a>, which is when the ball often pops out of the socket.</p>
<p>Shoulder instability may be caused by acute trauma (such as dislocation). Or it can develop over time from a loss of muscle control, deriving from micro-trauma (by, for example, swimming laps in the pool with hand paddles). </p>
<p>Shoulder instability is associated with <a href="https://www.mdpi.com/2077-0383/11/17/5140">reduced strength and coordination</a> in the shoulder muscles. In people under 40, it’s often <a href="https://pubmed.ncbi.nlm.nih.gov/24079437/?">misdiagnosed</a> as “rotator cuff pain” or “shoulder muscle tightness”.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520401/original/file-20230412-24-c6w2to.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some people are more flexible than others in the shoulder.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What can I do instead of dead hangs?</h2>
<p>Dead hangs require good baseline strength, can risk popping the ball from the socket for some people, and can stretch the passive tissue. They are not the best exercise for those for shoulder hypermobility and instability.</p>
<p>So what’s the alternative? A treatment known as the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023053/">Watson Instability Program</a> has had good <a href="https://journals.sagepub.com/doi/pdf/10.1177/0363546517734508">results</a> for resolving non-traumatic shoulder instability when compared to a general shoulder strength program. </p>
<p>This program focuses on gaining shoulder blade control (such as the upward rotation you get when you reach up to a high shelf). It involves recruiting the shoulder blade and shoulder joint muscles to improve the contact between the ball and the socket.</p>
<p>Building shoulder blade control and strength can help boost broader shoulder strength. </p>
<h2>Still keen to try dead hangs?</h2>
<p>If you are determined to do dead hangs, remember to:</p>
<ul>
<li><p>start with small increments; hang for just ten seconds or fewer at first, and build from there</p></li>
<li><p>don’t allow yourself to get too fatigued; your shoulder joint can become less stable when it’s tired</p></li>
<li><p>try stepping off a box under the bar rather than jumping up to the bar</p></li>
<li><p>keep some “active” tone in your shoulders as you hang; hanging completely passively can come with risk.</p></li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520659/original/file-20230413-20-msqtax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Try to keep some active tone in your muscles as you hang.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Our team is conducting a trial of the Watson Instability Program. We are investigating brain changes in patients with multidirectional instability of the shoulder. </p>
<p>If you’re female, aged 18-35, have non-traumatic, right-sided shoulder instability and would like to have the chance to receive six months of free Watson Instability Program physiotherapy treatment as part of our study, please contact either of us or read more about the study <a href="https://melbourneshouldergroup.com/fmri">here</a>.</p><img src="https://counter.theconversation.com/content/202346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charlotte Ganderton receives funding from Arthritis Australia, Physiotherapy Research Foundation, Swinburne University of Technology, National Institute of Circus Arts and La Trobe University. Charlotte Ganderton is a member of the Australian Physiotherapy Association and Sports Medicine Australia.</span></em></p><p class="fine-print"><em><span>Sarah Warby consults and receives research funds from the Melbourne Shoulder Group. </span></em></p>While dead hangs may be OK for people with good upper-body strength and no shoulder problems, they can be risky for some.Charlotte Ganderton, Senior lecturer (Physiotherapy), Swinburne University of TechnologySarah Warby, Casual Academic, Physiotherapy, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2028502023-04-16T20:04:13Z2023-04-16T20:04:13ZTurning down the volume of pain – how to retrain your brain when you get sensitised<figure><img src="https://images.theconversation.com/files/519223/original/file-20230404-22-zg86ma.jpg?ixlib=rb-1.1.0&rect=23%2C7%2C5152%2C2902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/close-up-photo-of-a-man-having-a-neck-pain-7298867/">Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>For every feeling we experience, there is a lot of complex biology going on underneath our skin. </p>
<p>Pain involves our whole body. When faced with possible threats, the feeling of pain develops in a split second and can help us to “detect and protect”. But over time, our nerve cells can become over-sensitised. This means they can react more strongly and easily to something that normally wouldn’t hurt or would hurt less. This is called “<a href="https://sitn.hms.harvard.edu/flash/2022/sensitization-why-everything-might-hurt/#:%7E:text=When%20neurons%20responsible%20for%20sensing,subset%20of%20chronic%20pain%20patients.">sensitisation</a>”.</p>
<p>Sensitisation can affect anyone, but some people may be more prone to it than others due to possible <a href="https://doi.org/10.1111/jabr.12137">genetic factors, environmental factors or previous experiences</a>. Sensitisation can contribute to chronic pain conditions like fibromyalgia, irritable bowel syndrome, migraine or low back pain.</p>
<p>But it might be possible to retrain our brains to manage or even reduce pain.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-three-people-with-chronic-pain-have-difficulty-accessing-ongoing-prescriptions-for-opioids-182678">One in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids</a>
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<h2>‘Danger!’</h2>
<p>Our body senses possible threats via nerve endings called <a href="https://www.sciencedirect.com/topics/neuroscience/nociceptor">nociceptors</a>. We can think of these like a microphones transmitting the word “danger” through wires (nerves and the spinal cord) up to a speaker (the brain). If you sprain your ankle, a range of tiny chemical reactions start there. </p>
<p>When sensitisation happens in a sore body part, it’s like more microphones join in over a period of weeks or months. Now the messages can be transmitted up the wire more efficiently. The volume of the danger message gets turned way up. </p>
<p>Then, in the spinal cord, chemical reactions and the number of receptors there also adapt to this new demand. The more messages coming up, the more reactions triggered and the louder the messages sent on to the brain.</p>
<p>And sensitisation doesn’t always stop there. The brain can also crank the volume up by making use of more wires in the spinal cord that reach the speaker. This is one of the proposed mechanisms of central sensitisation. As time ticks on, a sensitised nervous system will create more and more feelings of pain, seemingly regardless of the amount of bodily damage at the initial site of pain. </p>
<p>When we are sensitised, we may experience pain that is out of proportion to the actual damage (<a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hyperalgesia">hyperalgesia</a>), pain that spreads to other areas of the body (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327510/">referred pain</a>), pain that lasts a long time (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573040/">chronic or persistent pain</a>), or pain triggered by harmless things like touch, pressure or temperature (<a href="https://www.ncbi.nlm.nih.gov/books/NBK537129/#:%7E:text=Allodynia%20is%20defined%20as%20%22pain,produce%20sensation%2C%20causing%20pain.">allodynia</a>). </p>
<p>Because pain is a biopsychosocial experience (biological and psychological and social), we may also feel other symptoms like fatigue, mood changes, sleep problems or difficulty concentrating.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="little girl clutches tummy in pain" src="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Community education about pain might teach good habits from an early age.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-asian-girl-have-stomach-ache-2192335661">Shutterstock</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/for-people-with-chronic-pain-flexibility-and-persistence-can-protect-wellbeing-199008">For people with chronic pain, flexibility and persistence can protect wellbeing</a>
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<h2>Neuroplasticity</h2>
<p>Around the clock, our bodies and brain are constantly changing and adapting. <a href="https://www.ncbi.nlm.nih.gov/books/NBK557811/">Neuroplasticity</a> is when the brain changes in response to experiences, good or bad. </p>
<p>Pain science research suggests we may be able to <a href="https://www.nih.gov/news-events/nih-research-matters/retraining-brain-treat-chronic-pain">retrain</a> ourselves to improve wellbeing and take advantage of neuroplasticity. There are some promising approaches that target the mechanisms behind sensitisation and aim to reverse them.</p>
<p>One example is <a href="https://pubmed.ncbi.nlm.nih.gov/21306870/">graded motor imagery</a>. This technique uses mental and physical exercises like identifying left and right limbs, imagery and <a href="https://www.physio-pedia.com/Mirror_Therapy">mirror box therapy</a>. It has been <a href="https://www.tandfonline.com/doi/full/10.1080/24740527.2023.2188899">tested</a> for conditions like <a href="https://www.ninds.nih.gov/health-information/disorders/complex-regional-pain-syndrome">complex regional pain syndrome</a> (a condition that causes severe pain and swelling in a limb after an injury or surgery) and in <a href="https://www.ncbi.nlm.nih.gov/books/NBK448188/#:%7E:text=Phantom%20limb%20pain%20is%20the,underlying%20pathophysiology%20remains%20poorly%20understood.">phantom limb pain</a> after amputation. Very gradual exposure to increasing stimuli may be behind these positive effects on a sensitised nervous system. While results are promising, more research is needed to confirm its benefits and better understand how it works. The same possible mechanisms of graded exposure underpin some recently developed <a href="https://mhealth.jmir.org/2019/2/e13080/">apps</a> for sufferers.</p>
<p>Exercise can also retrain the nervous system. Regular physical activity can <a href="https://journals.physiology.org/doi/full/10.1152/japplphysiol.01317.2012">decrease the sensitivity</a> of our nervous system by changing processes at a cellular level, seemingly re-calibrating danger message transmission. Importantly, exercise doesn’t have to be high intensity or involve going to the gym. Low-impact activities such as walking, swimming, or yoga can be effective in reducing nervous system sensitivity, possibly by providing new evidence of perceived <a href="https://doi.org/10.1097/j.pain.0000000000002244">safety</a>.</p>
<p>Researchers are exploring whether learning about the science of pain and changing the way we think about it may foster self-management skills, like pacing activities and graded exposure to things that have been painful in the past. Understanding how pain is felt and why we feel it <a href="https://doi.org/10.1111/1756-185X.14293">can help</a> improve function, reduce fear and lower anxiety. </p>
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Read more:
<a href="https://theconversation.com/health-check-what-causes-headaches-42254">Health Check: what causes headaches?</a>
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<h2>But don’t go it alone</h2>
<p>If you have chronic or severe pain that interferes with your daily life, you should consult a health professional like a doctor and/or a pain specialist who can diagnose your condition and prescribe appropriate active treatments. </p>
<p>In Australia, a range of <a href="https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/212772/ACI-chronic-pain-services.pdf">multidisciplinary pain clinics</a> offer physical therapies like exercise, psychological therapies like mindfulness and cognitive behavioural therapy. Experts can also help you make lifestyle changes to improve <a href="https://painhealth.csse.uwa.edu.au/pain-module/sleep-and-pain/">sleep</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584994/">diet</a> to manage and reduce pain. A multi-pronged approach makes the most sense given the complexity of the underlying biology.</p>
<p>Education could help develop <a href="https://www.sciencedirect.com/science/article/abs/pii/S0738399121006467">pain literacy and healthy habits</a> to prevent sensitisation, even from a young age. Resources, such as children’s books, videos, and board games, are being developed and tested to improve <a href="https://doi.org/10.1016/j.jpain.2022.07.008">consumer and community understanding</a>.</p>
<p>Pain is not a feeling anyone should have to suffer in silence or endure alone. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-tips-for-building-kids-resilience-after-bumps-scrapes-and-other-minor-injuries-187022">5 tips for building kids' resilience after bumps, scrapes and other minor injuries</a>
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<img src="https://counter.theconversation.com/content/202850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Pate is the author of the pain science children's book series titled Zoe and Zak's Pain Hacks.</span></em></p>‘Sensitisation’ can affect anyone, but some people may be more prone to it than others due to genetic factors, environmental factors or previous experiences.Joshua Pate, Senior Lecturer in Physiotherapy, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1990082023-02-23T19:02:03Z2023-02-23T19:02:03ZFor people with chronic pain, flexibility and persistence can protect wellbeing<figure><img src="https://images.theconversation.com/files/511336/original/file-20230221-26-zuo73t.jpg?ixlib=rb-1.1.0&rect=110%2C80%2C6599%2C4386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-wearing-black-camisole-3356489/">Pexels/Engin Akyurt</a></span></figcaption></figure><p>Chronic pain affects around <a href="https://academic.oup.com/painmedicine/article/14/9/1346/1878427">one</a> in <a href="https://journals.lww.com/pain/Abstract/2022/02000/Prevalence_of_chronic_pain_among_adults_in_the.31.aspx">five</a> people and is considered “chronic” when it persists beyond the expected healing time, typically three months or longer. </p>
<p>Along with physical problems, chronic pain can impact a person’s daily activities, <a href="https://academic.oup.com/fampra/article/34/6/656/3748262">employment, lifestyle</a> and <a href="https://www.ochsnerjournal.org/content/17/2/173.abstract">mental health</a>. </p>
<p>Doing things you love and having goals are fundamental for wellbeing because they give <a href="https://www.sciencedirect.com/science/article/pii/S0165178116318108">meaning and purpose</a>. But pain can make doing the activities you enjoy psychologically, physically and/or <a href="https://psycnet.apa.org/record/2015-14817-002">emotionally</a> very <a href="https://www.sciencedirect.com/science/article/abs/pii/S0304395908004181">challenging</a>. </p>
<p>Our <a href="https://www.mdpi.com/1660-4601/20/2/1278">new research</a> shows the way a person with chronic pain responds to not being able to participate in the activities or goals they value can can impact their <a href="https://www.researchgate.net/publication/327410714_Goal_Adjustment_and_Well-Being_The_Role_of_Optimism_in_Patients_with_Chronic_Pain">mental wellbeing</a> – even more so than their pain levels.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-we-need-to-get-creative-when-it-comes-to-talking-about-pain-152257">Why we need to get creative when it comes to talking about pain</a>
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</em>
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<h2>Pain intensity vs interference</h2>
<p>We surveyed more than 300 people living chronic pain (that wasn’t related to cancer) about their mental wellbeing, “pain intensity” and how much pain interfered with the everyday pursuits and activities that mattered to them. </p>
<p>(We differentiated <a href="https://onlinelibrary.wiley.com/doi/full/10.1034/j.1399-6576.2001.450906.x">chronic pain from cancer pain</a> due to the differing prognoses and treatments available, and the unique psychological and social factors associated with cancer pain, such as concern about death.)</p>
<p>We found pain that disrupted daily life activities, rather than the intensity of the pain, posed the biggest threat to a person’s mental wellbeing. </p>
<p>When pain interferes with a person’s engagement in meaningful daily activities, it causes distress and <a href="https://journals.sagepub.com/doi/abs/10.1177/2049463718824857">decreases wellbeing</a>. </p>
<figure class="align-center ">
<img alt="Man's hands with arthritis" src="https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pain stops some people doing the things they find meaningful, like going to work.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/dNe6TyX_laM">Unsplash/Towfiqu Barbhuiya</a></span>
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<p>The research suggests it’s possible for people to find ways to maintain their mental wellbeing, even when their pain intensity is high, so long as they’re able to maintain aspects of life that are important to them, such as relationships and work.</p>
<h2>People with pain find other ways of doing things</h2>
<p>We found personal motivational traits – specifically, goal flexibility (adjusting goals in response to changing circumstances and setbacks) and tenacity (persistently striving to achieve a desired goal under difficult circumstances) – were associated with increases in mental wellbeing for people living with chronic pain. </p>
<p>Although flexibility and persistence were both associated with increased mental wellbeing, the capacity to flexibly adjust to setbacks or obstacles had the most significant positive effect in maintaining one’s mental wellbeing. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-5-aussies-over-45-live-with-chronic-pain-but-there-are-ways-to-ease-the-suffering-137891">1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering</a>
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<p>Flexibility appears to act as a protective factor against the impacts of pain interference on mental wellbeing, to a greater extent than personal tenacity or persistence.</p>
<p>There is often more than one way to modify or adapt an activity when difficulties arise. A walk on the beach with friends, for instance, may be adjusted to meeting at the beach for coffee to fulfil the same goal or value: social connectedness.</p>
<h2>Focusing on people’s strengths rather than deficits</h2>
<p>Psychological processes that can help people to live well in the face of long-term pain have long been overlooked. Research has traditionally focused on unhelpful thought processes that perpetuate or exacerbate mental distress. For example, <a href="https://www.tandfonline.com/doi/full/10.2147/JPR.S64730">pain catastrophising</a> and repeated <a href="https://psycnet.apa.org/record/2015-14817-002">negative</a> <a href="https://pubmed.ncbi.nlm.nih.gov/21283147/">self-criticism</a>.</p>
<p>Pain management and mental health are multi-faceted. Previous research has shown <a href="https://www.sciencedirect.com/science/article/pii/S0007091219302272">pain management</a> should take into account physical factors (age, sleep, injury, disease) and social factors (employment, social support, economic factors).</p>
<figure class="align-center ">
<img alt="Older man with walking stick walks next to small white dog" src="https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Research has tended to focus on the negative thought processes of people with chronic pain, rather than the positive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-tall-stooped-man-stick-walks-1808227138">Shutterstock</a></span>
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<p>Our findings add to this body of knowledge. For those living with pain, reappraising and adjusting meaningful life activities and goals, when needed, in response to setbacks or life challenges can help maintain mental wellbeing.</p>
<p>These findings can inform the development of psychological supports for people with chronic pain. In turn, these supports could identify <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590174/">internal strengths</a>, resources, positive coping strategies, self-efficacy, hope and wellbeing – and promote psychological strengths rather than deficits.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/endometriosis-costs-women-and-society-30-000-a-year-for-every-sufferer-124975">Endometriosis costs women and society $30,000 a year for every sufferer</a>
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<img src="https://counter.theconversation.com/content/199008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joanne Dickson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows the way a person with chronic pain responds to limitations to the activities or goals they value can impact their mental wellbeing – even more so than their pain levels.Joanne Dickson, Professor of Psychology & Mental Health, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993842023-02-10T13:52:21Z2023-02-10T13:52:21ZUse of psychedelics to treat PTSD, OCD, depression and chronic pain – a researcher discusses recent trials, possible risks<figure><img src="https://images.theconversation.com/files/508513/original/file-20230206-29-xiko4j.jpg?ixlib=rb-1.1.0&rect=89%2C0%2C7336%2C3540&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are some possible health issues with the drugs, including cardiovascular risks.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/creative-background-royalty-free-image/1352156068?phrase=PSYCHEDELICS&adppopup=true">wildpixel/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>New research is exploring whether psychedelic drugs, taken under strict medical supervision, might help in treating post-traumatic stress disorder, chronic pain, depression and obsessive-compulsive disorder. SciLine interviewed <a href="https://profiles.ucsf.edu/jennifer.mitchell">Dr. Jennifer Mitchell</a> – a professor in the Departments of Neurology and Psychiatry & Behavioral Science in the School of Medicine at the University of California, San Francisco – to discuss what scientists have found so far about the effectiveness of these drugs in treating these disorders and how they might safely be administered.</em></p>
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<figcaption><span class="caption">Dr. Jennifer Mitchell discusses psychedelic medicine.</span></figcaption>
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<p><em>The Conversation has collaborated with SciLine to bring you highlights from the discussion, which have been edited for brevity and clarity.</em></p>
<p><strong>What are psychedelic drugs and how do they work?</strong></p>
<p><strong>Jennifer Mitchell:</strong> Psychedelic <a href="https://www.verywellmind.com/types-of-psychedelic-drug-22073">basically means “mind manifesting</a>,” suggesting that the compound assists one in uncovering subject matter that perhaps is otherwise deeply hidden from the conscious mind. </p>
<p>It’s a slightly different term from hallucinogen, which you see used almost interchangeably at times with the term psychedelic. </p>
<p>A hallucinogen by definition is something that makes you see, hear, smell something that isn’t otherwise there, so you can imagine there’s a lot of overlap between psychedelics and hallucinogens. </p>
<p><strong>Which types of psychedelic drugs are being studied by researchers for potential therapeutic use?</strong></p>
<p><strong>Jennifer Mitchell:</strong> The two most well studied drugs at this point are MDMA and psilocybin. </p>
<p><a href="https://nida.nih.gov/publications/drugfacts/mdma-ecstasymolly">MDMA</a> is being evaluated mainly for treatment of post-traumatic stress disorder treatments, and <a href="https://adf.org.au/drug-facts/psilocybin/">psilocybin</a> mainly for treatment of resistant depression and major depressive disorder. </p>
<p>MDMA is the furthest along because there’s phase 3 data (data from late-stage research) and the possibility that a new drug application would be submitted to the FDA sometime later this year. </p>
<p><a href="https://www.dea.gov/factsheets/lsd">LSD</a> is also being evaluated for a number of different indications, most notably obsessive-compulsive disorder. </p>
<p>And then a couple of sort of heavier hitters are now being tested in primarily healthy control populations, including drugs like <a href="https://clinicaltrials.gov/ct2/results?cond=&term=mescaline&cntry=&state=&city=&dist=">mescaline</a> and <a href="https://clinicaltrials.gov/ct2/results?cond=&term=ayahuasca&cntry=&state=&city=&dist=">ayahuasca</a>.</p>
<p><strong>What have scientists discovered about whether these drugs are effective in treating health problems like PTSD or chronic pain?</strong></p>
<p><strong>Jennifer Mitchell:</strong> The drugs so far <a href="https://doi.org/10.1038/s41591-021-01336-3">appear to be quite effective</a>. I think one key, though, is that they’re typically being administered in conjunction with some form of psychotherapy. </p>
<p>So it’s important to keep that in mind when we look at the <a href="https://doi.org/10.1016/j.eclinm.2022.101809">results from some of these recent trials</a> that these are not drugs that are being administered in isolation. You are not taking home a bottle of pills and taking those twice a day as you would, say, an antidepressant. These are administered in a very particular way.</p>
<p><strong>What is involved in therapeutic treatment using these drugs?</strong></p>
<p><strong>Jennifer Mitchell:</strong> Typically, prior to taking the drug at all, subjects participate in a number of preparatory sessions so that they understand a little bit about what is going to happen on an experimental session day. </p>
<p>And then subjects come into a room that looks very much like a comfortable living room, and they spend all day there. The drug is administered typically in the morning. For psilocybin, you’re looking at a six-hour dosing session, and for MDMA, an eight-hour dosing session. </p>
<p>You are in the company of a group of trained providers: therapists, psychedelic facilitators, psychiatrists and clinical research coordinators.</p>
<p><strong>What are the potential risks of using psychedelic drugs for therapeutic purposes?</strong></p>
<p><strong>Jennifer Mitchell:</strong> One concern we’ve had is cardiovascular risk, and so we are taking great care in some of the clinical trials at present <a href="https://doi.org/10.1002/cpdd.796">to evaluate cardiovascular burden</a>, including heart attack risk, during and after the experiment. This evaluation includes tracking the heart rate and blood pressure of the participants.</p>
<p>In addition, researchers are worried about suicidality, in part because these are treatment-resistant populations that we’re starting off with, and so there’s a concern that perhaps, if they’re destabilized – either by the psychedelic, or just by tapering off their other meds in order to be part of a psychedelic trial – that we could run the risk of suicidality. </p>
<p>Lastly, I think the FDA has been concerned about the possibility that psychedelics are addictive, and so we’ve been following up with study participants to ensure that they aren’t engaging in drug seeking or drug taking outside of the study.</p>
<p><strong>What do we know about the safety of taking psychedelics outside the clinical context?</strong></p>
<p><strong>Jennifer Mitchell:</strong> I think we’ve all heard stories from the ‘60s and '70s of people taking psychedelics and <a href="https://www.verywellmind.com/what-is-a-bad-trip-22071">having very bad experiences</a>. What we know now is that the environment in which you take the psychedelic is of the utmost importance. It’s not appropriate at this point to try to take some of these substances or replicate some of these protocols on your own without oversight. </p>
<p><em>Watch the <a href="https://www.sciline.org/mental-health/psychedelic-medicine/">full interview</a> to hear more about psychedelic medicine.</em></p>
<p><em><a href="https://www.sciline.org/">SciLine</a> is a free service based at the nonprofit American Association for the Advancement of Science that helps journalists include scientific evidence and experts in their news stories.</em></p><img src="https://counter.theconversation.com/content/199384/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Mitchell has received funding from MAPS and currently serves on the Research Advisory Panel within the California Department of Justice.</span></em></p>The early research suggests the drugs might be effective for some conditions. But scientists have safety concerns.Jennifer Mitchell, Professor of Neurology, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869012023-02-09T13:35:20Z2023-02-09T13:35:20ZCBD is not a cure-all – here’s what science says about its real health benefits<figure><img src="https://images.theconversation.com/files/488378/original/file-20221005-18-19r1y.jpg?ixlib=rb-1.1.0&rect=440%2C26%2C5514%2C3961&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Since 2018, it has been legal in the U.S. to use a drug made from purified cannabis-derived cannabidiol – CBD – to treat certain childhood seizure disorders.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/scientist-checking-cannabis-plants-in-marijuana-royalty-free-image/1298557693?adppopup=true">Visoot Uthairam/Moment via Getty Images</a></span></figcaption></figure><p>Over the last five years, an often forgotten piece of U.S. federal legislation – the Agriculture Improvement Act of 2018, also known as the <a href="https://www.fda.gov/news-events/congressional-testimony/hemp-production-and-2018-farm-bill-07252019">2018 Farm Bill</a> – has ushered in an <a href="https://peoria.medicine.uic.edu/cbd-blog/">explosion of interest</a> in the medical potential of cannabis-derived cannabidiol, or CBD. </p>
<p>After decades of debate, the bill made it legal for farmers to grow industrial hemp, <a href="https://www.nifa.usda.gov/industrial-hemp">a plant rich in CBD</a>. Hemp itself has tremendous value as a cash crop; it’s used to produce biofuel, textiles and animal feed. But the CBD extracted from the hemp plant also has numerous medicinal properties, with <a href="https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476#">the potential to benefit millions</a> through the treatment of seizure disorders, pain or anxiety. </p>
<p>Prior to the bill’s passage, the resistance to legalizing hemp was due to its association with marijuana, its biological cousin. Though hemp and marijuana belong to the same species of plant, <em>Cannabis sativa</em>, they each have a unique chemistry, <a href="https://doi.org/10.1177%2F2045125312457586">with very different characteristics and effects</a>. Marijuana possesses tetrahydrocannabinol, or THC, <a href="https://nida.nih.gov/publications/research-reports/marijuana/how-does-marijuana-produce-its-effects">the chemical that produces the characteristic high</a> that is associated with cannabis. Hemp, on the other hand, is a strain of the cannabis plant that contains virtually no THC, and <a href="https://www.cdc.gov/marijuana/featured-topics/CBD.html#">neither it nor the CBD derived from it</a> can produce a high sensation. </p>
<p><a href="https://pennstate.pure.elsevier.com/en/persons/kent-vrana">As a professor and chair</a> of the <a href="https://scholar.google.com/citations?user=B7QZGgoAAAAJ&hl=en">department of pharmacology</a> at Penn State, I have been following research developments with CBD closely and have seen some promising evidence for its role in treating a broad range of medical conditions.</p>
<p>While there is growing evidence that CBD can help with certain conditions, caution is needed. Rigorous scientific studies are limited, so it is important that the marketing of CBD products does not get out ahead of the research and of robust evidence.</p>
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<figcaption><span class="caption">Before purchasing any CBD products, first discuss it with your doctor and pharmacist.</span></figcaption>
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<h2>Unpacking the hype behind CBD</h2>
<p>The primary concern about CBD marketing is that the scientific community is not sure of the best form of CBD to use. CBD can be produced as either a pure compound or a complex mixture of molecules from hemp that constitute <a href="https://www.healthline.com/nutrition/cbd-oil-benefits">CBD oil</a>. CBD can also be formulated as a <a href="https://www.healthline.com/health/best-cbd-cream-for-pain#A-quick-look-at-the-best-CBD-creams-for-pain">topical cream or lotion</a>, or as a <a href="https://www.drugs.com/lifestyle/cbd-gummies-health-benefits-3515165/">gummy</a>, <a href="https://www.medicalnewstoday.com/articles/best-cbd-capsules#how-to-shop">capsule</a> or <a href="https://www.medicalnewstoday.com/articles/cbd-oil-vs-tincture#risks">tincture</a>. </p>
<p>Guidance, backed by clinical research, is needed on the best dose and delivery form of CBD for each medical condition. That research is still in progress.</p>
<p>But in the meantime, the siren’s call of the marketplace has sounded and created an environment in which CBD is often <a href="https://www.nbcnews.com/health/health-news/even-without-proof-cbd-finding-niche-cure-all-n945516">hyped as a cure-all</a> – an elixir <a href="https://www.forbes.com/health/body/cbd-for-sleep/#">for insomnia</a>, <a href="https://www.healthline.com/health/cbd-for-anxiety">anxiety</a>, <a href="https://www.health.harvard.edu/blog/cbd-for-chronic-pain-the-science-doesnt-match-the-marketing-2020092321003">neuropathic pain</a>, <a href="https://www.mdanderson.org/cancerwise/cbd-oil-and-cancer--9-things-to-know.h00-159306201.html">cancer</a> and <a href="https://www.acc.org/About-ACC/Press-Releases/2022/09/06/14/48/As-CBD-Use-Rises-Clinical-Trials-Needed-to-Determine-Safety-Efficacy-in-Heart-Disease-Patients">heart disease</a>. </p>
<p>Sadly, there is precious little rigorous scientific evidence to support many of these claims, and much of the existing research has been performed in animal models. </p>
<p>CBD is simply <a href="https://doi.org/10.1038/d41586-019-02524-5">not a panacea for all that ails you</a>.</p>
<h2>Childhood seizure disorders</h2>
<p>Here’s one thing that is known: Based on rigorous trials with hundreds of patients, CBD has been shown to be a <a href="https://www.neurocenternj.com/blog/cbd-for-seizures-use-effectiveness-side-effects-and-more/#">proven safe and effective drug for seizure disorders, particularly in children</a>. </p>
<p>In 2018, the U.S. Food and Drug Administration granted regulatory approval for the use of a purified <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-comprised-active-ingredient-derived-marijuana-treat-rare-severe-forms">CBD product sold under the brand name Epidiolex</a> for the treatment of <a href="https://medlineplus.gov/genetics/condition/lennox-gastaut-syndrome/">Lennox-Gastaut</a> and <a href="https://dravetfoundation.org/what-is-dravet-syndrome/">Dravet syndromes</a> in children. </p>
<p>These two rare syndromes, appearing early in life, produce large numbers of frequent seizures that are <a href="https://www.neurologylive.com/view/childhood-epilepsies-dravet-and-lennox-gastaut-syndromes">resistant to traditional epilepsy treatments</a>. CBD delivered as an oral solution as Epidiolex, however, <a href="https://doi.org/10.3389/fphar.2020.00063">can produce a significant reduction</a> – greater than 25% – in the frequency of seizures in these children, with 5% of the patients becoming seizure-free. </p>
<h2>More than 200 scientific trials</h2>
<p>CBD is what pharmacologists call a promiscuous drug. That means it could be effective for treating a number of medical conditions. In broad strokes, CBD affects more than one process in the body – a <a href="https://theconversation.com/many-medications-affect-more-than-one-target-in-the-body-some-drug-designers-are-embracing-the-side-effects-that-had-been-seen-as-a-drawback-184922">term called polypharmacology</a> – and so could benefit more than one medical condition.</p>
<p>As of early 2023, there are <a href="https://clinicaltrials.gov/ct2/results?cond=&term=cannabidiol&cntry=US&state=&city=&dist=">202 ongoing or completed scientific trials</a> examining the effectiveness of CBD in humans on such diverse disorders as chronic pain, substance use disorders, anxiety and arthritis. </p>
<p>In particular, CBD appears to be <a href="https://www.ncbi.nlm.nih.gov/books/NBK547742/">an anti-inflammatory agent and analgesic</a>, similar to the functions of aspirin. This means it might be helpful for treating people suffering with inflammatory pain, like arthritis, or headaches and body aches. </p>
<p>CBD also holds potential for use in <a href="https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/chemotherapy.html">cancer therapy</a>, although it has not been approved by the FDA for this purpose. </p>
<p>The potential for CBD in the context of cancer is twofold: </p>
<p>First, there is evidence that it <a href="https://doi.org/10.3390/biom11040582">can directly kill cancer cells</a>, enhancing the ability of traditional therapies to treat the disease. This is not to say that CBD will replace those traditional therapies; the data is not that compelling. </p>
<p>Second, because of its ability to reduce pain and perhaps anxiety, the addition of CBD to a treatment plan may <a href="https://doi.org/10.3390/biom11040582">reduce side effects</a> and increase the quality of life for people with cancer.</p>
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<figcaption><span class="caption">Things to consider before purchasing a CBD product.</span></figcaption>
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<h2>The risks of unregulated CBD</h2>
<p>While prescription CBD is safe when used as directed, other forms of the molecule come with risks. This is especially true for CBD oils. The over-the-counter CBD oil industry <a href="https://www.forbes.com/health/body/cbd-legalization-by-state/">is unregulated and not necessarily safe</a>, in that there are no regulatory requirements for monitoring what is in a product. </p>
<p>What’s more, rigorous science does not support the unsubstantiated marketing claims made by many CBD products. </p>
<p>In a <a href="https://doi.org/10.1159/000489287">2018 commentary</a>, the author describes the results of his own study, which was published in Dutch (in 2017). His team obtained samples of CBD products from patients <a href="https://www.researchgate.net/publication/321679450_Grote_variatie_in_samenstelling_cannabisolie_noopt_tot_regels">and analyzed their content</a>. Virtually none of the 21 samples contained the advertised quantity of CBD; indeed, 13 had little to no CBD at all and many contained significant levels of THC, the compound in marijuana that leads to a high – and that was not supposed to have been present. </p>
<p>In fact, studies have shown that there is <a href="https://theconversation.com/the-dietary-supplement-youre-taking-could-be-tainted-with-prescription-medications-and-dangerous-hidden-ingredients-according-to-a-new-study-181418">little control of the contaminants that may be present</a> in over-the-counter products. The FDA has <a href="https://www.fda.gov/news-events/public-health-focus/warning-letters-and-test-results-cannabidiol-related-products">issued scores of warning letters</a> to companies that market unapproved drugs containing CBD. In spite of the marketing of CBD oils as all-natural, plant-derived products, consumers should be aware of the risks of unknown compounds in their products or unintended interactions with their prescription drugs. </p>
<p>Regulatory guidelines for CBD <a href="https://www.statnews.com/2023/02/03/fda-right-agency-regulate-cbd-products-but-it-needs-help/">are sorely lacking</a>. Most recently, in January 2023, the FDA concluded that the existing framework is “not appropriate for CBD” and said it would work with Congress to chart a way forward. In a statement, the agency said that “<a href="https://www.fda.gov/news-events/press-announcements/fda-concludes-existing-regulatory-frameworks-foods-and-supplements-are-not-appropriate-cannabidiol">a new regulatory pathway for CBD is needed</a> that balances individuals’ desire for access to CBD products with the regulatory oversight needed to manage risks.” </p>
<p>As a natural product, CBD is still acting as a drug – much like aspirin, acetaminophen or even a cancer chemotherapy. Health care providers simply need to better understand the risks or benefits.</p>
<p>CBD may <a href="https://www.health.harvard.edu/blog/cbd-and-other-medications-proceed-with-caution-2021011121743#">interact with the body in ways that are unintended</a>. CBD is eliminated from the body by the same liver enzymes that remove a variety of drugs such as blood thinners, antidepressants and organ transplant drugs. Adding CBD oil to your medication list without consulting a physician could be risky and could interfere with prescription medications. </p>
<p>In an effort to help prevent these unwanted interactions, my colleague Dr. Paul Kocis, a clinical pharmacist, and I have created a free online application called the <a href="https://cann-dir.psu.edu/">CANNabinoid Drug Interaction Resource</a>. It identifies how CBD could potentially interact with other prescription medications. And we urge all people to disclose both over-the-counter CBD or recreational or medical marijuana use to their health care providers to prevent undesirable drug interactions.</p>
<p>In the end, I believe that CBD will prove to have a <a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">place in people’s medicine cabinets</a> – but not until the medical community has established the right form to take and the right dosage for a given medical condition.</p><img src="https://counter.theconversation.com/content/186901/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kent E Vrana receives unrestricted research grant funding from PA Options for Wellness (a Pennsylvania-approved clinical registrant medical marijuana company).
Vrana is the director of the Pennsylvania-designated Medical Marijuana Academic Clinical Research Center at Penn State. </span></em></p>CBD isn’t a miracle cure for everything that ails a person – but science shows that it has the potential to help treat a number of health conditions.Kent E Vrana, Professor and Chair of Pharmacology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1976622023-01-24T13:23:27Z2023-01-24T13:23:27ZYoga: Modern research shows a variety of benefits to both body and mind from the ancient practice<figure><img src="https://images.theconversation.com/files/505654/original/file-20230120-8209-dd2jmr.jpg?ixlib=rb-1.1.0&rect=252%2C347%2C6774%2C4340&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Yoga mixes physical exercise with meditation and breathing techniques.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/yoga-class-on-mats-in-studio-in-gentle-twist-royalty-free-image/1305098935?phrase=yoga%20group&adppopup=true">10,000 Hours/Digital Vision via Getty Images</a></span></figcaption></figure><p>The popularity of yoga has grown tremendously in the past decade. More than 10% of U.S. adults <a href="https://doi.org/10.1089/acm.2020.0506">have practiced yoga</a> at some point in their lives. Yoga practitioners spend on average US$90 a month, and the yoga industry is worth more than <a href="https://comparecamp.com/yoga-statistics/">$80 billion worldwide</a>. </p>
<p>Yoga is now a mainstream activity in the U.S. and is commonly portrayed as a healthy lifestyle choice. <a href="https://scholar.google.com/citations?user=Ar2ww04AAAAJ&hl=en&oi=ao">I am a behavioral scientist</a> who researches how physical activity – and specifically yoga – can prevent and help manage chronic diseases.</p>
<p>Many people attribute improvements in their physical and mental health to their yoga practice. But until recently, research had been sparse on the health benefits of yoga. As the body of rigorous research on yoga grows, more and more work is showing the many health benefits of a yoga practice. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A statue of a man sitting with legs crossed." src="https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505655/original/file-20230120-24-xurvux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The sage Patanjali wrote the first texts on yoga nearly 2,000 years ago.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Patanjali_Statue.jpg#/media/File:Patanjali_Statue.jpg">Alokprasad/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>What is yoga?</h2>
<p>The name “yoga” is derived from the Sanskrit word “Yuj” meaning to unite, join or connect the mind, body and soul. The first text on yoga was <a href="https://yoga.ayush.gov.in/Yoga-History/#:%7E:text=The%20practice%20of%20Yoga%20is,first%20Guru%20or%20Adi%20Guru">written by the sage Patanjali</a> over 2,000 years ago in India. Patanjali described yoga as “citta-vrtti-nirodhah,” or “stilling the mind.” This was achieved through a mix of breath work, meditation, physical movement and body purification practices, as well as ethical and moral codes for living a healthy and purposeful life.</p>
<p>Over the years, various yoga teachers have modified the original Patanjali yoga, resulting in different styles that vary in their intensity and focus. For example, some yoga styles such as <a href="https://www.arhantayoga.org/blog/what-is-vinyasa-yoga/?utm_source=google&utm_medium=cpc&utm_campaign=16798733686&utm_content=&utm_term=&gclid=Cj0KCQiA_bieBhDSARIsADU4zLeu55jBq4b-83qV9FGkLb6voLdHYDVD8-9dzNPX44WhozJvslby0RYaApn3EALw_wcB">Vinyasa</a> focus more on intense movements similar to an aerobic workout. <a href="https://chopra.com/articles/restorative-yoga-the-basics-5-poses">Restorative yoga</a> includes more relaxation poses. <a href="https://iynaus.org/what-is-iyengar-yoga/">Iyengar yoga</a> uses props and emphasizes precision and proper alignment of body. These different styles provide options for individuals with different physical abilities.</p>
<p>Generally speaking, yoga instructors in the U.S. today teach styles that incorporate postures, breathing exercises and sometimes meditation.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zbG9LQst6EA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Modern Western yoga often uses poses like downward dog that focus on flexibility and strength.</span></figcaption>
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<h2>What does the research show?</h2>
<p>As yoga has grown in popularity in recent years, researchers have begun to study its effects and are finding that it has great benefit for mental and physical health.</p>
<p>Yoga involves physical movement, so it is no surprise that most types of yoga can help to improve a person’s strength and flexibility. In one study with healthy untrained volunteers, researchers found that eight weeks of yoga improved <a href="https://doi.org/10.1111/j.1520-037x.2001.00542.x">muscular strength at the elbow and knee by 10%-30%</a>. Flexibility at the ankle, shoulder and hip joints also increased by 13%-188%.</p>
<p>There are a number of less obvious but meaningful benefits from yoga as well. Research has shown that yoga practice can <a href="https://doi.org/10.1016/j.ijcard.2014.02.017">reduce risk factors for heart disease</a> such as high blood pressure, high cholesterol and abdominal obesity. Studies on older adults have shown significant improvements in <a href="https://doi.org/10.1093/ageing/afv175">balance, mobility</a>, <a href="https://doi.org/10.1016/j.archger.2020.104319">cognitive function</a> and <a href="https://doi.org/10.1186/s12966-019-0789-2">overall quality of life</a>. </p>
<p>Yoga seems to be effective at managing pain, too. Research has found that yoga can improve symptoms of <a href="https://doi.org/10.1007/s11606-019-05413-9">headaches</a>, <a href="https://doi.org/10.1007/s11926-019-0846-5">osteoarthritis</a>, <a href="https://doi.org/10.1097%2FMD.0000000000014649">neck pain</a> and <a href="https://doi.org/10.1002/14651858.CD010671">low-back pain</a>. In fact, the American College of Physicians recommends yoga as one of the options for initial nonpharmaceutical <a href="https://doi.org/10.7326/M16-2367">treatment for chronic low-back pain</a>.</p>
<p>Yoga also provides many benefits for mental health. Researchers have found that a regular practice over eight to 12 weeks can lead to moderate <a href="https://doi.org/10.1002/da.22762">reductions in anxiety</a> and <a href="http://dx.doi.org/10.1136/bjsports-2019-101242">depressive symptoms</a> as well as help with <a href="https://pubmed.ncbi.nlm.nih.gov/32088671/">stress management</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of people sitting on yoga mats with their hands pressed together in front of their chests." src="https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505657/original/file-20230120-16-kadb2e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mindfulness is an important part of yoga practice and has been linked to many health benefits.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mature-woman-doing-yoga-in-class-royalty-free-image/1349259739?phrase=yoga%20sitting%20group&adppopup=true">SeventyFour/iStock via Getty Images</a></span>
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</figure>
<h2>More than physical exercise</h2>
<p>Yoga is a type of exercise in that it is a form of physical exertion that helps build fitness. A lot of the benefits researchers have found are due to the physical activity component and are similar to <a href="https://doi.org/10.1089/acm.2009.0044">benefits from other forms of exercise</a> like running, weightlifting or calisthenics. </p>
<p>But unlike these other activities, yoga practice incorporates mindfulness as a key aspect. With its focus on controlling breath, holding postures and meditation, yoga increases how much a person pays attention to the sensations of their body and the present moment. This <a href="https://theconversation.com/meditation-and-mindfulness-offer-an-abundance-of-health-benefits-and-may-be-as-effective-as-medication-for-treating-certain-conditions-195276">mindfulness leads to many benefits</a> not found from other forms of exercise.</p>
<p>Studies have shown that mindfulness training on its own can increase a person’s self-awareness, along with the ability to recognize and <a href="https://doi.org/10.1037/0022-3514.84.4.822">skillfully respond to emotional stress</a>. It can even give a person greater control over long-term behavior. One study found that increased mindfulness from yoga can help people better recognize and respond to feelings of being full when eating, decrease binge eating and <a href="https://doi.org/10.1080/10640266.2020.1798172">alleviate concerns over how their body looks</a>.</p>
<p>My colleagues and I observed a similar effect in a pilot study on the benefits of yoga for individuals with Type 2 diabetes. After doing yoga twice a week for three months, several participants reported paying more attention to their diet, snacking less and eating healthier, <a href="https://doi.org/10.1016%2Fj.ctcp.2018.11.011">even without any nutrition intervention</a>. Our patients also reported less stress and an increased willingness to engage in other types of physical activities.</p>
<p>Yoga is clearly different from Western exercise in how it approaches mental health. With more research, it may be possible to understand the biological mechanisms as well.</p>
<h2>Things to know if you want to start doing yoga</h2>
<p>Yoga may not be helpful for all medical conditions or right for every person, but people of all age groups, body types and physical abilities can practice yoga. It can be a form of mental and physical exercise for people who do not enjoy sweating during strenuous forms of exercise or for individuals with medical or physical conditions who find working out in the gym challenging.</p>
<p>It is important to consider that although yoga is generally safe, just as with any other form of exercise, there is some <a href="https://doi.org/10.1186/s12906-019-2612-7">risk of getting injured</a>. Individuals with medical conditions who are new to yoga should practice it initially under the supervision of a trained instructor. </p>
<p>If you do decide to give yoga a try, talk to the yoga instructor first to assess whether the style they offer meets your preference and fitness levels. Remember, you may need to practice a couple of weeks to feel the benefits, physically and mentally.</p><img src="https://counter.theconversation.com/content/197662/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Herpreet Thind receives funding from the National Institute of Health. </span></em></p>Yoga’s surge in popularity in the past decade has spurred more research into its effects. The combination of physical movement and mindfulness provides a wide range of health benefits.Herpreet Thind, Associate Professor of Public Health, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892882022-12-22T16:56:00Z2022-12-22T16:56:00ZChronic pain: An invisible disease whose sufferers are unfairly stigmatized<figure><img src="https://images.theconversation.com/files/481359/original/file-20220826-2852-t3iovl.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even though chronic pain is recognized by scientists as a disease in its own right, it remains largely under-recognized, under-diagnosed and, above all, subject to many prejudices. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine living with pain every day for months, or even years — pain that is so intrusive, it disrupts every day of your life.</p>
<p>Unfortunately, this is the daily reality of millions of people living with chronic pain. And all too often, they find their condition being stigmatized or even denied outright.</p>
<p>As a doctoral student in the epidemiology of chronic pain, I have the opportunity to work with patient partners. Given the high prevalence and multiple impacts of this disease, it is high time we started working to change attitudes and confront the prejudices that surround it.</p>
<h2>Essential pain and acute pain</h2>
<p>Before discussing chronic pain, let’s start at the beginning. Is pain always a negative thing? Of course not. Pain is essential to our proper functioning. It acts as an <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">alarm system</a> to warn us of danger.</p>
<p>For example, if we were to accidentally put our hand on a hot stove top, a pain message would be sent to our brain. Before we even had time to think about it, we would remove our hand from the hot surface, avoiding an intense burn in the process. This pain provides us with the reflexes we need in order to avoid the worst situations.</p>
<p>Pain can also last a little longer. This is the case, for example, after an injury, an operation or an infection. <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">This pain will often resolve itself after a normal healing cycle</a> or disappear with the help of treatment. This is called acute pain. Short-term pain like this is perceived more as a symptom.</p>
<h2>Chronic pain, a disease with multiple impacts</h2>
<p>When pain persists beyond the normal healing time, it is no longer considered simply a symptom, but a <a href="https://doi.org/10.1097/j.pain.0000000000000160">disease in its own right</a>. This is called chronic pain. Chronic pain is defined as <a href="https://doi.org/10.1097/j.pain.0000000000001384">pain that persists for a minimum of three months</a>. Yet, for the vast majority of people living with this disease, the pain persists for several years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Displacement,’ by Chloe Fleisher, 13, who lives with chronic pain. Submitted as part of the art contest titled ‘Pain and mental health,’ this artwork won an award from the Canadian Pain Society in 2022.</span>
<span class="attribution"><span class="source">(Marimée Godbout-Parent)</span></span>
</figcaption>
</figure>
<p>In these people, the pain message is somehow missing. It is no longer present to warn us of dangers, but becomes a burden on its own. Chronic pain can occur as a result of cancer, an accident, or after surgery. Unfortunately, sometimes we are unable to find the cause. This makes it difficult to treat.</p>
<p>Although this disease is not widely recognized, it is estimated to affect about <a href="https://doi.org/10.24095/hpcdp.31.4.04">20 per cent of the Canadian population</a>. Considering that our population in 2022 is estimated to be close to 39 million, this would mean that approximately 7.5 million people are living with chronic pain. For the purpose of comparison, 7.5 million Canadians is equivalent to <a href="https://worldpopulationreview.com/canadian-provinces/quebec-population">the entire population of Québec</a>. It’s an impressive and worrisome number.</p>
<p>In addition to affecting a large portion of the population, chronic pain <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">causes more than just physical pain</a>. The disease affects the daily functioning, psychological well-being, quality of life, social life and work of the people afflicted by it.</p>
<p>Imagine having so much pain that it reduces your ability to work, play with your children, see your friends or concentrate and even affects your ability to carry out everyday tasks. Despite the person’s desire to stay active, the body just can’t keep up. So it’s not surprising that consequences such as fatigue, frustration, sadness, anxiety and depression follow. The constant overlap between physical, psychological and social difficulties creates deep distress in this population.</p>
<h2>A stigmatized disease</h2>
<p>Despite the significant impacts associated with it, <a href="https://doi.org/10.1111/j.1526-4637.2011.01264.x">chronic pain remains largely stigmatized</a>. Indeed, negative attitudes and beliefs that people living with chronic pain <a href="https://doi.org/10.1080/24740527.2017.1369849">have become dependent on their medications, that they are exaggerating the severity of their condition, are just lazy</a> or do not want to help themselves are widespread.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IcdsYdUls44?wmode=transparent&start=48" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Chronic pain is a very real disease.</span></figcaption>
</figure>
<p>So, knowing the multiple consequences and prevalence of chronic pain, why is there still so much prejudice and stigma towards those who suffer from it?</p>
<p>The question remains unanswered. For some, what we cannot see simply does not exist. Because pain is an experience that varies from person to person, because we don’t have a specific tool for detecting it or because we can’t necessarily see it, pain can seem invisible. We have a harder time feeling <a href="https://doi.org/10.1016/j.jpain.2013.11.002">sympathy or understanding for things that cannot be explained medically</a> with medical tests or X-rays.</p>
<h2>How to become an ally</h2>
<p>So, despite the many explanations offered by patients, they often have to deal with prejudices from health professionals, their entourage or the general population. Many people living with chronic pain feel that their pain is not understood by their friends, family, employers or even their health-care professionals, which adds to their feelings of helplessness, sadness and anger. In addition to dealing with the difficulties that chronic pain brings, these comments place an inestimable burden on sufferers. </p>
<p>Francine, who has been living with chronic pain for 15 years, regularly receives these types of comments from her family and friends:</p>
<blockquote>
<p>Well, you’ve only been walking for 10 minutes, you can do more. Just try harder.</p>
</blockquote>
<p>Sylvie, who has lived with chronic pain for 17 years, has to deal with her doctor’s comments:</p>
<blockquote>
<p>“You are the only patient I have not been able to relieve with cortisone shots in 40 years, so perhaps you should consult a psychologist instead.</p>
</blockquote>
<p>These phrases, which can sound harmless to some, are often loaded with meaning for those who hear them on a daily basis. Accepting chronic pain as a disease is an important and difficult step. It should not be coupled with such pejorative comments.</p>
<p>Without being experts in the field, we can all play a role, in one way or another, in the lives of these people. Offering an active and understanding ear, not making quick judgments and acknowledging their condition is already a huge step in the right direction.</p>
<p>Support and communication with those around you are elements that should not be neglected and can certainly make a positive difference.</p>
<p><em>This article was written in collaboration with Sylvie Beaudoin and Christian Bertrand, patient partners.</em></p><img src="https://counter.theconversation.com/content/189288/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marimée Godbout-Parent has received funding from the Canadian Institutes of Health Research (CIHR).</span></em></p>Although chronic pain is recognized by scientists as a disease in its own right, it remains largely under-recognized, under-diagnosed and, above all, associated with numerous prejudices.Marimée Godbout-Parent, Étudiante au doctorat recherche en sciences de la santé, Université du Québec en Abitibi-Témiscamingue (UQAT)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869062022-11-02T12:29:49Z2022-11-02T12:29:49ZCannabis holds promise for pain management, reducing the need for opioid painkillers – a neuropharmacology expert explains how<figure><img src="https://images.theconversation.com/files/477967/original/file-20220808-82349-qkr00w.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The cannabis plant produces both THC – the psychoactive component in marijuana – and the compound commonly known as CBD, which does not lead to a 'high.'</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/marijuana-leaves-background-royalty-free-image/1329249971?adppopup=true">Jena Ardell/Moment via Getty Images</a></span></figcaption></figure><p>Drug overdose deaths from opioids <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm">continue to rise in the U.S.</a> as a result of both the misuse of <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">prescription opioids and the illicit drug market</a>. </p>
<p>But an interesting trend has developed: <a href="https://www.upmc.com/media/news/071221-drake-cannabisrcl">Opioid emergency room visits</a> drop by nearly 8% and <a href="https://doi.org/10.1007%2Fs11606-018-4782-2">opioid prescriptions</a> are modestly lower in <a href="https://www.usatoday.com/story/news/nation/2022/10/06/how-many-states-have-legalized-marijuana-cannabis-laws-unpacked/8200166001/">states where marijuana is legalized</a>. </p>
<p>Marijuana is produced by the cannabis plant, which is native to Asia but is now grown throughout the world. Individuals use marijuana for both its psychoactive, euphoria-inducing properties and its ability to <a href="https://doi.org/10.1002/j.1552-4604.1975.tb02348.x">relieve pain</a>. </p>
<p>Chemicals produced by the cannabis plant are commonly known as cannabinoids. The <a href="https://www.nccih.nih.gov/health/cannabis-marijuana-and-cannabinoids-what-you-need-to-know">two primary cannabinoids</a> that occur naturally in the cannabis plant are THC – the psychoactive compound in marijuana – and CBD, which does not cause the sensation of being high.</p>
<p>Many <a href="https://doi.org/10.1377/hlthaff.2018.05266">marijuana users say</a> they take it to treat pain, suggesting that readily available cannabinoids could potentially be used to offset the use of opioids such as morphine and oxycodone that are commonly used in pain treatment. A safer, natural alternative to opioid painkillers would be an important step toward <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">addressing the ongoing opioid epidemic</a>. </p>
<p>Intriguingly however, research suggests that cannabis use could also lessen the need for opioids directly by interacting with the body’s own natural <a href="https://doi.org/10.1097/j.pain.0000000000002527">opioid system</a> to produce similar pain-relief effects.</p>
<p>I am <a href="https://pharmacology.uw.edu/team-member/benjamin-land/">a neuropharmacology scientist</a> who <a href="https://scholar.google.com/citations?user=dux-xtoAAAAJ&hl=en">studies both opioids and cannabinoids</a> as they relate to pain treatment and substance abuse. My research focuses on the development of drug compounds that can provide chronic pain relief without the potential for overuse and without the tapering off of effectiveness that often accompanies traditional pain medications.</p>
<h2>How opioids work</h2>
<p>Our bodies have their own built-in opioid system that can aid in managing pain. These opioids, <a href="https://www.health.harvard.edu/mind-and-mood/endorphins-the-brains-natural-pain-reliever">such as endorphins</a>, are chemicals that are released when the body experiences stress such as strenuous exercise, as well as in response to pleasurable activities like eating a good meal. But it turns out that humans are not the only organisms that can make opioids. </p>
<p>In the 1800s, scientists discovered that <a href="https://www.history.com/topics/crime/history-of-heroin-morphine-and-opiates#">the opioid morphine</a> – isolated from opium poppy – was highly effective at relieving pain. In the last 150 years, scientists have developed additional synthetic opioids like hydrocodone and dihydrocodeine that also provide pain relief.</p>
<p>Other opioids like heroin and oxycodone are very similar to morphine, but with small differences that influence how quickly they act on the brain. Fentanyl has an even more unique chemical makeup. It is <a href="https://www.dea.gov/factsheets/fentanyl">the most powerful opioid</a> and is the culprit behind the <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">current surge in drug overdoses and deaths</a>, <a href="https://www.uclahealth.org/news/adolescent-drug-overdose-deaths-rose-exponentially-first">including among young people</a>.</p>
<p>Opioids, whether naturally produced or synthetic, produce pain relief by binding to specific receptors in the body, which are proteins that act like a lock that can only be opened by an opioid key.</p>
<p>One such receptor, <a href="https://doi.org/10.1124%2Fpr.112.007138">known as the mu-opioid receptor</a>, is found on pain-transmitting nerve cells along the spinal cord. When activated, mu-receptors tamp down the cell’s ability to relay pain information. Thus, when these opioids are circulating in the body and they reach their receptor, stimuli that would normally cause pain are not transmitted to the brain.</p>
<p>These same receptors are also found in the brain. When opioids find their receptor, the brain releases <a href="https://www.health.harvard.edu/mind-and-mood/feel-good-hormones-how-they-affect-your-mind-mood-and-body">dopamine – the so-called “feel-good” chemical</a> – which has its own receptors. This is in part why opioids can be highly addicting. Research suggests that these receptors drive the <a href="https://doi.org/10.1016/j.biopsych.2019.05.023">brain’s reward system</a> and promote further drug-seeking. For people who are prescribed opiates, this creates the potential for abuse. </p>
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<figcaption><span class="caption">Opioid drugs, which include heroin, oxycodone and fentanyl, are highly addictive.</span></figcaption>
</figure>
<p>Opioid receptors are dynamically regulated, meaning that as they get exposed to more and more opioids, the body adapts quickly by deactivating the receptor. In other words, the body needs more and more of that opioid to get pain relief and to produce the feel-good response. This process is known as tolerance. The drive to seek more and more reward paired with an ever-increasing tolerance is what leads to the potential for overdose, which is why opioids are generally not long-term solutions for pain. </p>
<h2>The potential of THC and CBD for pain treatment</h2>
<p>Both THC and CBD have been shown in <a href="https://doi.org/10.2174/157015906778019527">numerous</a> <a href="https://pubmed.ncbi.nlm.nih.gov/20073408/">studies</a> to lessen pain, though – importantly – they differ in which receptors they bind to in order to produce these effects.</p>
<p>THC binds to cannabinoid receptors that are located throughout the central nervous system, producing a variety of responses. One of those responses is the high associated with cannabis use, and another is pain relief. Additionally, THC is believed to reduce inflammation in a manner <a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">similar to anti-inflammatory drugs like ibuprofen</a>. </p>
<p>In contrast, CBD appears to bind to <a href="https://doi.org/10.1111/bcpt.13710">several distinct receptors</a>, and many of these receptors can play a role in pain reduction. Importantly, this occurs without the high that occurs with THC. </p>
<p>Because they target different receptors, THC and CBD may be more effective working in concert <a href="https://doi.org/10.3390/ijms23158649">rather than alone</a>, but more studies in <a href="https://doi.org/10.2217/pmt-2020-0110">animal models and humans are needed</a>.</p>
<p>Cannabinoids may also be helpful for other conditions as well. Many studies have demonstrated that cannabinoid drugs approved for medical use are effective for pain and other symptoms like <a href="https://www.ninds.nih.gov/health-information/disorders/spasticity#">spasticity</a>, nausea and <a href="https://doi.org/10.1186/s12916-022-02459-1">appetite loss</a>.</p>
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<figcaption><span class="caption">The opioid crisis: Painkillers are killing us.</span></figcaption>
</figure>
<h2>Moving pain research forward</h2>
<p>Along with the pairing of THC and CBD, researchers are beginning to explore the use of those two cannabinoids together with existing opioids for pain management. This research is being done in <a href="https://doi.org/10.1038/s41386-022-01322-4">both animal models and humans</a>. </p>
<p>These studies are designed to understand both the benefits – pain relief – and risks – primarily addiction potential – of co-treatment with cannabinoids and opioids. The hope would be that THC or CBD may lower the amount of opioid necessary for powerful pain relief without increasing addiction risk.</p>
<p>For example, one study tested the <a href="https://doi.org/10.1038/s41386-018-0011-2">combination of smoked cannabis and oxycontin</a> for pain relief and reward. It found that co-treatment enhanced pain relief but also increased the pleasure of the drugs. This, as well as a limited number of other <a href="https://doi.org/10.1038/s41386-022-01322-4">studies</a>, suggests there may not be a net benefit.</p>
<p>However, many more studies of this type will be necessary to understand if cannabinoids and opioids can be safely used together for pain. Still, using cannabinoids as a substitution for opioids remains a promising pain treatment strategy. </p>
<p>The next decade of research will likely bring important new insights to the therapeutic potential of cannabinoids for chronic pain management. And as <a href="https://www.politico.com/news/2022/08/03/cannabis-legalization-efforts-across-the-states-00049224">marijuana legalization continues to spread</a> across the U.S., its use in medicine will undoubtedly grow exponentially.</p><img src="https://counter.theconversation.com/content/186906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Land receives funding from the NCCIH for cannabinoid work distinct from opioids, and has received cannabinoid related funding from the University of Washington Addiction and Drug Abuse Institute and SCAN Design Foundation.</span></em></p>Studies suggest that marijuana and CBD use might help relieve chronic pain while also reducing a patient’s need for opioids.Benjamin Land, Research Associate Professor of Pharmacology, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738042022-06-24T11:52:20Z2022-06-24T11:52:20ZHow do painkillers actually kill pain? From ibuprofen to fentanyl, it’s about meeting the pain where it’s at<figure><img src="https://images.theconversation.com/files/470376/original/file-20220622-11-ijs4h6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A variety of pain-relieving drugs are available both over the counter and by prescription.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-woman-looking-at-prescription-bottles-royalty-free-image/150684340">SelectStock/Vetta via Getty Images</a></span></figcaption></figure><p>Without the ability to feel pain, life is more dangerous. To avoid injury, pain tells us to use a hammer more gently, wait for the soup to cool or put on gloves in a snowball fight. Those with <a href="https://www.ncbi.nlm.nih.gov/books/NBK481553/">rare inherited disorders</a> that leave them without the ability to feel pain are unable to protect themselves from environmental threats, leading to broken bones, damaged skin, infections and ultimately a shorter life span.</p>
<p>In these contexts, pain is much more than a sensation: It is a protective call to action. But pain that is too intense or long-lasting can be debilitating. So how does modern medicine soften the call?</p>
<p>As a <a href="https://scholar.google.com/citations?user=Hn7sPk0AAAAJ&hl=en">neurobiologist</a> and an <a href="https://www.anesthesiology.pitt.edu/people/benedict-alter-md-phd">anesthesiologist</a> who study pain, this is a question we and other researchers have tried to answer. Science’s understanding of how the body senses tissue damage and perceives it as pain has progressed tremendously over the past several years. It has become clear that there are <a href="https://doi.org/10.1126/science.aaf8933">multiple pathways</a> that signal tissue damage to the brain and sound the pain alarm bell. </p>
<p>Interestingly, while the brain uses different pain signaling pathways depending on the type of damage, there is also redundancy to these pathways. Even more intriguing, these neural pathways morph and amplify signals in the case of <a href="https://doi.org/10.1097/j.pain.0000000000001384">chronic pain</a> and pain caused by <a href="https://doi.org/10.1152/physrev.00045.2019">conditions affecting nerves themselves</a>, even though the protective function of pain is no longer needed.</p>
<p>Painkillers work by tackling different parts of these pathways. Not every painkiller works for every type of pain, however. Because of the multitude and redundancy of pain pathways, a perfect painkiller is elusive. But in the meantime, understanding how existing painkillers work helps medical providers and patients use them for the best results.</p>
<h2>Anti-inflammatory painkillers</h2>
<p>A bruise, sprain or broken bone from an injury all lead to tissue <a href="https://my.clevelandclinic.org/health/symptoms/21660-inflammation">inflammation</a>, an immune response that can lead to swelling and redness as the body tries to heal. Specialized nerve cells in the area of the injury called <a href="https://www.verywellhealth.com/what-are-nociceptors-2564616">nociceptors</a> sense the inflammatory chemicals the body produces and send pain signals to the brain. </p>
<p>Common over-the-counter <a href="https://doi.org/10.1016/j.anclin.2017.01.020">anti-inflammatory painkillers</a> work by decreasing inflammation in the injured area. These are particularly useful for musculoskeletal injuries or other pain problems caused by inflammation such as arthritis. </p>
<p>Nonsteroidal anti-inflammatories like ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin do this by blocking an enzyme called <a href="https://www.ncbi.nlm.nih.gov/books/NBK549795/">COX</a> that plays a key role in a biochemical cascade that produces inflammatory chemicals. Blocking the cascade decreases the amount of inflammatory chemicals, and thereby reduces the pain signals sent to the brain. While acetaminophen (Tylenol), also known as paracetamol, doesn’t reduce inflammation as NSAIDs do, it also inhibits COX enzymes and has similar pain-reducing effects.</p>
<p>Prescription anti-inflammatory painkillers include other COX inhibitors, corticosteroids and, more recently, drugs that target and <a href="https://doi.org/10.1186/s10194-017-0807-1">inactivate the inflammatory chemicals</a> themselves.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/9mcuIc5O-DE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Aspirin and ibuprofen work by blocking the COX enzymes that play a key role in pain-causing processes.</span></figcaption>
</figure>
<p>Because inflammatory chemicals are involved in other important physiological functions beyond just sounding the pain alarm, medications that block them will have side effects and potential health risks, including irritating the stomach lining and affecting <a href="https://doi.org/10.1161/01.hyp.0000116221.27079.ea">kidney function</a>. <a href="https://medlineplus.gov/ency/article/002123.htm">Over-the-counter medications</a> are generally safe if the directions on the bottle are followed strictly.</p>
<p><a href="https://www.verywellhealth.com/using-corticosteroids-for-pain-control-2564537">Corticosteroids</a> like prednisone block the inflammatory cascade early on in the process, which is probably why they are so potent in reducing inflammation. However, because all the chemicals in the cascade are present in nearly every organ system, long-term use of steroids can pose many health risks that need to be discussed with a physician before starting a treatment plan.</p>
<h2>Topical medications</h2>
<p>Many <a href="https://doi.org/10.1002/14651858.cd008609.pub2">topical medications</a> target nociceptors, the specialized nerves that detect tissue damage. Local anesthetics, like lidocaine, prevent these nerves from sending electrical signals to the brain. </p>
<p>The protein sensors on the tips of other sensory neurons in the skin are also targets for topical painkillers. Activating these proteins can elicit particular sensations that can lessen the pain by reducing the activity of the damage-sensing nerves, like the cooling sensation of menthol or the burning sensation of capsaicin.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand holding small container of topical ointment" src="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Certain topical ointments, like menthol and capsaicin, can crowd out pain signals with different sensations.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/topical-ointment-royalty-free-image/1328896655">Photography By Tonelson/iStock via Getty Images</a></span>
</figcaption>
</figure>
<p>Because these topical medications work on the tiny nerves in the skin, they are best used for pain directly affecting the skin. For example, a <a href="https://doi.org/10.2147%2FJMDH.S106340">shingles infection</a> can damage the nerves in the skin, causing them to become overactive and send persistent pain signals to the brain. Silencing those nerves with topical lidocaine or an overwhelming dose of capsaicin can reduce these pain signals.</p>
<h2>Nerve injury medications</h2>
<p><a href="https://doi.org/10.1152/physrev.00045.2019">Nerve injuries</a>, most commonly from arthritis and diabetes, can cause the pain-sensing part of the nervous system to become overactive. These injuries sound the pain alarm even in the absence of tissue damage. The best painkillers in these conditions are those that dampen that alarm.</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/in-depth/pain-medications/art-20045004">Antiepileptic drugs</a>, such as gabapentin (Neurontin), suppress the pain-sensing system by blocking electrical signaling in the nerves. However, gabapentin can also reduce nerve activity in other parts of the nervous system, potentially leading to sleepiness and confusion.</p>
<p><a href="https://www.mayoclinic.org/pain-medications/art-20045647">Antidepressants</a>, such as duloxetine and nortriptyline, are thought to work by increasing certain neurotransmitters in the spinal cord and brain involved in regulating pain pathways. But they may also alter chemical signaling in the gastrointestinal tract, leading to an upset stomach.</p>
<p>All these medications are prescribed by doctors.</p>
<h2>Opioids</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/18443637/">Opioids</a> are chemicals found or derived from the opium poppy. One of the earliest opioids, morphine, was purified in the 1800s. Since then, medical use of opioids has expanded to include many natural and synthetic derivatives of morphine with varying potency and duration. Some common examples include codeine, tramadol, hydrocodone, oxycodone, buprenorphine and fentanyl.</p>
<p>Opioids decrease pain by activating the body’s endorphin system. <a href="https://www.ncbi.nlm.nih.gov/books/NBK470306/">Endorphins</a> are a type of opioid your body naturally produces that decreases incoming signals of injury and produces feelings of euphoria – the so-called “runner’s high.” Opioids simulate the effects of endorphins by acting on similar targets in the body.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NDVV_M__CSI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">While opioids can provide strong pain relief, they are not meant for long-term use because they are addictive.</span></figcaption>
</figure>
<p>Although opioids can decrease some types of acute pain, such as after surgery, musculoskeletal injuries like a broken leg or <a href="https://doi.org/10.1002%2F14651858.CD012592.pub2">cancer pain</a>, they are often ineffective for <a href="https://doi.org/10.1001/jama.2018.18472">neuropathic injuries and chronic pain</a>. </p>
<p>Because the body uses opioid receptors in other organ systems like the gastrointestinal tract and the lungs, side effects and risks include constipation and potentially fatal suppression of breathing. Prolonged use of opioids may also lead to <a href="https://www.merckmanuals.com/home/drugs/factors-affecting-response-to-drugs/tolerance-and-resistance-to-drugs">tolerance</a>, where more drug is required to get the same painkilling effect. This is why opioids can be addictive and are not intended for long-term use. All opioids are controlled substances and are carefully prescribed by doctors because of these side effects and risks.</p>
<h2>Cannabinoids</h2>
<p>Although cannabis has received a lot of attention for its potential medical uses, there <a href="https://doi.org/10.1002/phar.2115">isn’t sufficient evidence available</a> to conclude that it can effectively treat pain. Since the use of cannabis is <a href="https://www.investopedia.com/marijuana-legality-by-state-4844504">illegal at the federal level</a> in the U.S., high-quality clinical research funded by the federal government has been lacking. </p>
<p>Researchers do know that the body naturally produces <a href="https://doi.org/10.1038/npp.2017.204">endocannabinoids</a>, a form of the chemicals in cannabis, to decrease pain perception. Cannabinoids may also reduce inflammation. Given the lack of strong clinical evidence, physicians typically don’t recommend them over FDA-approved medications.</p>
<h2>Matching pain to drug</h2>
<p>While sounding the pain alarm is important for survival, dampening the klaxon when it’s too loud or unhelpful is sometimes necessary. </p>
<p>No existing medication can perfectly treat pain. Matching specific types of pain to drugs that target specific pathways can improve pain relief, but even then, medications can fail to work even for people with the same condition. More research that deepens the medical field’s understanding of the pain pathways and targets in the body can help lead to more effective treatments and improved pain management.</p><img src="https://counter.theconversation.com/content/173804/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Seal receives funding from National Institutes of Health</span></em></p><p class="fine-print"><em><span>Benedict Alter receives funding from National Institutes of Health, Foundation for Anesthesia Education and Research, and the International Anesthesia Research Society. </span></em></p>Different painkillers provide relief in different ways. The most effective medication is the one that best targets the type of pain you’re experiencing with minimal side effects.Rebecca Seal, Associate Professor of Neurobiology, University of PittsburghBenedict Alter, Assistant Professor of Anesthesiology and Perioperative Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1812292022-05-30T20:21:54Z2022-05-30T20:21:54ZWhy stress-related illness is so hard to diagnose, and how a patient-centred playful approach can help<figure><img src="https://images.theconversation.com/files/466093/original/file-20220530-14-e9ztvz.jpg?ixlib=rb-1.1.0&rect=147%2C0%2C3636%2C2121&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because of stigma and deeply rooted implicit bias, people who suffer chronic and unexplained pains are often characterized as complainers, malingerers and drug-seekers. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>For at least three decades, researchers have gathered evidence that chronic stress puts pressure on the body to constantly adjust itself to restore physiological stability. This process is known as <a href="https://www.sciencedirect.com/topics/neuroscience/allostatic-load">allostatic load</a> and it creates a cascade of toxic metabolic activities that cause wear and tear on the body. </p>
<p>Allostatic load makes people vulnerable to various types of cardiac, gastrointestinal, endocrinological, immunological, neurological, metabolic and psychiatric problems. </p>
<p>Evidence is emerging to show that <a href="https://doi.org/10.1159/000510696">psychosocial and economic stressors influence health outcomes</a>. But neither our physicians, nor our health-care systems, have the necessary tools and methods to integrate those social and economic factors into our diagnoses or preventive care. </p>
<p>Here is a personal example: Recently, I called my physician to report mysterious new pains. The thorough investigation and note-taking that followed would have been very useful if I had suffered a specific infection or injury, or if my blood work was imperfect. But I had symptoms that began slowly and were increasing in frequency with COVID- and work-related stresses. </p>
<p>The more she pressed for identifying how, where and when exactly my pains had begun, the more I felt guilty about my imprecise condition. When I joked that I just needed a month to hang out with Freud in the Alps, she suggested prescribing antidepressants. Falling back to self-blaming humour: “Maybe this is all psychosomatic,” I said. </p>
<h2>Stigma of unexplained pains</h2>
<p>Far too many people have these experiences. The stigma and implicit biases against those who suffer chronic and unexplained pains (as <a href="https://doi.org/10.1503/cmaj.109-5553">complainers, malingerers and drug-seekers</a>) are <a href="http://dx.doi.org/10.1136/medhum-2016-011133">deeply rooted</a>. They are <a href="https://www.harpercollins.com/products/doing-harm-maya-dusenbery?variant=32208022110242">gendered</a>. They are <a href="https://dx.doi.org/10.1016%2Fj.jpain.2010.12.002">racial</a>, too. </p>
<p>While it is known that stress and <a href="https://doi.org/10.1177%2F00333549141291S206">social and economic disparities make people sick</a>, physicians do not have the necessary tools to fix those causes of illness. At best, next to medications, they can offer psychotherapy, which <a href="https://doi.org/10.9778/cmajo.20190094">remains inaccessible</a> and unaffordable to most. Our health-care system is also unequipped to address the <a href="https://doi.org/10.1177%2F1363461514557202">psychosocial determinants of health, which are situational and cultural</a>, so they require more than a clinical approach to care.</p>
<p>For example, <a href="https://doi.org/10.1016/j.ssmph.2020.100563">research on prescription of pain killers for racial and ethnic minorities</a> shows that Black patients’ pain is undertreated. This reflects a lack of trust in the symptoms reported by those who may already be suffering other forms of socio-economic disparity. The 2020 death of Joyce Echaquan, enduring abuse and untreated pain in a Québec hospital, made it <a href="https://principedejoyce.com/sn_uploads/principe/Joyce_s_Principle_brief___Eng.pdf">impossible to ignore the problem of health inequity any longer</a>. </p>
<h2>How combative approaches create stigma</h2>
<figure class="align-center ">
<img alt="Black and white images of a woman with a red patch of pain in various locations" src="https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=233&fit=crop&dpr=1 600w, https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=233&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=233&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=292&fit=crop&dpr=1 754w, https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=292&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/466092/original/file-20220530-14-hrq6uo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=292&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nearly 20 per cent of Canadians suffer chronic pain. For health-care providers, pain is whatever the experiencing person says it is and exists whenever the experiencing person says it does.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Since at least the publication of the <a href="https://doi.org/10.1177/09677720221079826">first epidemiological study in 1662</a>, we have been trying to predict and minimize causes of mortality. Science and technology are expected to help us win the battle against disease and disability. There is a particular <a href="https://doi.org/10.2147/AMEP.S246658">structural worldview that shapes our current medical culture</a>. It takes a combative approach to illness: it <em>fights</em> cancer, opioid epidemics, depression, diabetes and other conditions. </p>
<p>Implicitly, combative cultures value and reward winners. When we praise heroes (for example, <a href="https://www.cbc.ca/shortdocs/features/how-to-live-to-100-life-advice-from-centenarians">100-year-old people who enjoy active lives</a>), we implicitly turn those who fail to losers. This is how patients and their caregivers <a href="https://www.basicbooks.com/titles/arthur-kleinman/the-illness-narratives/9781541647121/">co-create stigma and shame associated with chronic illness</a> or even <a href="https://press.uchicago.edu/ucp/books/book/chicago/A/bo3625122.html">aging</a>. </p>
<p>Fortunately, a shift has begun towards <a href="https://doi.org/10.1016/S2214-109X(21)00301-6">epistemic justice</a>, which recognizes culturally appropriate practices and traditional knowledge, and <a href="http://DOI.org/10.1007/978-3-319-39724-5_14">patient-centred</a> health-care practices are emerging. <a href="https://doi.org/10.1186/s12939-021-01475-6">Indigenous leadership in de-colonizing health care</a> will accelerate these efforts. For the health-care system to begin acting on those principles, a <a href="http://doi.org/10.3389/fpain.2022.857624">shift towards more flexible, qualitative and ecological research methodologies is needed</a>. </p>
<h2>Why play matters</h2>
<p>In 1509, the Renaissance scholar Erasmus wrote <a href="https://www.gutenberg.org/files/30201/30201-h/30201-h.htm"><em>In Praise of Folly</em></a> to argue that play is an existential necessity that helps humans confront the inevitability of aging and death by becoming forgetful and carefree (like children). </p>
<p>Different forms of play are offered by <a href="http://doi.org/10.1002/9781119140467">therapists</a> or <a href="https://doi.org/10.1179/0969926013Z.00000000073">hospices</a> to facilitate communication over difficult or terminal health conditions.</p>
<p>In <a href="https://press.uchicago.edu/ucp/books/book/chicago/S/bo3620295.html"><em>Steps To an Ecology of Mind</em></a> (1971), anthropologist Gregory Bateson offered play as an experimental space for communication and learning <em>from learning</em> where people can simulate, interpret and evaluate the outcomes of their choices in a framed, but flexible, playground. </p>
<p>Indeed, play is a well-known research tool in <a href="https://www.worldcat.org/title/play-dreams-and-imitation-in-childhood/oclc/1156242941?loc=">developmental psychology</a>, <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674005815">anthropology</a>, <a href="https://doi.org/10.4324/9780203167403">economics</a> and <a href="https://doi.org/10.7551/mitpress/7995.001.0001">military strategies</a>.</p>
<p>In the context of a <a href="https://www.ucl.ac.uk/pals/sites/pals/files/jama_insel_2017_vp_170119.pdf">global drive for digital tracking and profiling of potential causes of illness</a>, my research colleagues and I have recently suggested <a href="https://doi.org/10.3389/fpsyt.2021.746477">that <em>play</em> offers an alternative way</a> of approaching research and taking action in this digital ecosystem. </p>
<h2>Prescribing play</h2>
<figure class="align-center ">
<img alt="A person in a white coat with a stethoscope around their neck holding a rolled-up green yoga mat" src="https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/466116/original/file-20220530-18-pgcx65.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Imagine if the frame of caring for me was a bit more flexible to allow my doctor to prescribe a yoga regime, or help me [explore a mindfulness program.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p><a href="https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2021.html">Twenty per cent of people</a> suffer from chronic pain. What do we do when we cannot “win” the battle against pain? Often, drug prescriptions offer the cheapest and fastest-acting remedies. But they don’t always work and the <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">side-effects can be disastrous</a>. This is why consensus is growing <a href="https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_2">among the World Health Organization members to invest in researching alternative ways of care</a>.</p>
<p>In <a href="https://www.penguinrandomhouse.com/books/203913/homo-ludens-by-johan-huizinga/"><em>Homoludens</em></a> (1938), historian Johan Huizinga showed that play is a uniquely human tendency to create imaginative aesthetics and rituals that give different meanings to the acts of satisfying biological needs such as shelter, food and safety. </p>
<p><a href="https://doi.org/10.3389/fpain.2022.895443">Indeed, play can become a creative and knowledge-generating act</a>. <a href="https://doi.org/10.2105%2FAJPH.2008.156497">Creative art therapy or expressive writings</a> can help track and control what causes pain. </p>
<p>Imagine if instead of pushing me to provide precise numbers for the intensity and frequency of my pain, I were allowed to <a href="https://journals.lww.com/psychosomaticmedicine/Abstract/1998/07000/Culture_and_Somatization__Clinical,.6.aspx">use metaphor</a> and be playful about explaining my symptoms and needs to my physician.</p>
<p>Imagine if the frame of caring for me was a bit more flexible to allow my doctor to <a href="https://doi.org/10.1177%2F2156587217715927">prescribe a yoga regime</a>, or help me <a href="https://doi.org/10.1007/s12160-016-9844-2">explore a mindfulness program</a>.</p>
<p>Imagine if clinicians incorporated Indigenous ways of knowing to <a href="https://doi.org/10.3389/fpain.2022.857624">LISTEN to pain (language, individual, share, teachable moments, engage and navigate)</a>.</p>
<p>Imagine if public health officials did not wait until chronic stress made the population prone to illness, and instead invested in <a href="https://www.jstor.org/stable/24719525">happiness policies like those in the Netherlands, the country of Erasmus and Huizinga</a>.</p>
<h2>Turning play to action</h2>
<p>When knowledge and care are lacking (<a href="https://doi.org/10.3389/fpain.2022.889990">for example, for women with endometrosis</a>), social media becomes a space for knowledge generation. <a href="https://mitpress.mit.edu/books/coping-illness-digitally">In <em>Coping with Illness Digitally</em></a>, health and digital communications researcher Stephan Rains illustrates that people connect to communities that offer information and care through shared experiences. </p>
<p>The COVID-19 pandemic illustrated the capacity of social media for <a href="https://doi.org/10.2196/20550">generating data</a> about coping with stress. However, if we are to be <a href="https://doi.org/10.1016/0361-3682(91)90019-B">governed by numbers</a>, we need a playground where we <a href="https://theconversation.com/the-covid-19-pandemic-pushed-social-media-to-become-increasingly-tribal-178775">are safe and not passively surveyed</a>. In a real playground, participants are not under surveillance, but are engaged in generating knowledge about psychosocial stressors that make them ill. Platforms such as <a href="https://www.patientslikeme.com">Patients Like Me</a> provide a blueprint for adding our narratives of stress-generated illnesses and coping strategies.</p><img src="https://counter.theconversation.com/content/181229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Najmeh Khalili-Mahani has received funding from FRQSC.</span></em></p>Psychosocial and economic stressors can affect health, but neither our doctors nor our health-care system have the tools to integrate these factors into diagnoses or care. Play offers an alternative.Najmeh Khalili-Mahani, Researcher, Director of Media-Health/Game-Clinic laboratory, Concordia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826782022-05-12T04:22:01Z2022-05-12T04:22:01ZOne in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids<figure><img src="https://images.theconversation.com/files/462365/original/file-20220511-17639-wu5i5a.jpg?ixlib=rb-1.1.0&rect=50%2C40%2C6659%2C4426&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/upset-mature-woman-suffering-backache-after-1504807832">Shutterstock</a></span></figcaption></figure><p><a href="https://pubmed.ncbi.nlm.nih.gov/11166468/">One in five</a> Australians live with chronic pain lasting three months or more. <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">Common causes include</a> back and neck pain, headache, and joint pain. </p>
<p>Opioid medicines – such as oxycodone, morphine, fentanyl and codeine – are essential medicines and <a href="https://pubmed.ncbi.nlm.nih.gov/32100394/">provide relief</a> to many people with this type of pain. </p>
<p>However, opioids can also cause <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012509.pub2/full">side effects</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/25581257/">harms</a> including dependence and <a href="https://pubmed.ncbi.nlm.nih.gov/29498021/">overdose</a>, which <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324425/">may be</a> <a href="https://pubmed.ncbi.nlm.nih.gov/28826104/">fatal</a>.</p>
<p>Over the past decade, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698322/">measures have been introduced in Australia</a> to curb growing rates of opioid use and harms. But this has come at the expense of access for some people who genuinely need them. </p>
<p>In our <a href="https://www.sciencedirect.com/science/article/abs/pii/S095539592200127X">new study</a>, one-third of participants prescribed opioids long-term for chronic, non-cancer pain had difficulties getting ongoing prescriptions. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-5-aussies-over-45-live-with-chronic-pain-but-there-are-ways-to-ease-the-suffering-137891">1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering</a>
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<h2>Tightening access</h2>
<p>In 2018, <a href="https://www.nps.org.au/australian-prescriber/articles/changes-for-codeine">codeine</a> was made a “<a href="https://www.tga.gov.au/codeine-info-hub">prescription-only</a>” medicine. In the same year, Australia’s Chief Medical Officer <a href="https://www1.racgp.org.au/newsgp/professional/government-to-warn-almost-5000-gps-over-high-rates">wrote to doctors</a> prescribing a lot of opioids to encourage them to consider reducing their prescribing. </p>
<p>States have also <a href="https://pubmed.ncbi.nlm.nih.gov/26937665/">introduced</a> <a href="https://www.nps.org.au/assets/p164-Dobbin-Liew-v2.pdf">prescription monitoring programs</a>, allowing providers to see whether their patients are getting opioids from other doctors or pharmacies.</p>
<figure class="align-center ">
<img alt="Patient talks to a pharmacist at the counter." src="https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In some states, doctors and pharmacists can check if patients are getting scripts elsewhere.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-medical-face-mask-talking-customer-1696625050">Shutterstock</a></span>
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</figure>
<p>We’re underaking a <a href="https://ndarc.med.unsw.edu.au/project/point-study-pain-and-opioids-treatment">long-term study</a> of just over 1,500 Australians prescribed opioids for chronic non-cancer pain. We started asking questions about accessing opioid prescriptions in our 2018 interviews with participants. </p>
<p>These weren’t prescriptions for new pain conditions, but ongoing prescriptions for people who had been <a href="https://pubmed.ncbi.nlm.nih.gov/25599444/">using these medicines for four years</a>, on average, and living with pain for ten years, before the study.</p>
<h2>Opioids can cause significant harm</h2>
<p>Over the past 30 years, the amount of opioids (doses per Australian per day) dispensed on the Pharmaceutical Benefits Scheme (PBS) <a href="https://pubmed.ncbi.nlm.nih.gov/26991673/">has increased four-fold</a>. </p>
<p>There has also been a <a href="https://www.publish.csiro.au/ah/AH18245">15-fold increase</a> in opioid prescriptions dispensed on the PBS between 1995 and 2015. Australia <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">currently ranks eighth</a> among <a href="https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2015/NAR-tech_pub_2015.pdf">countries using the most opioids</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
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<p>As opioid use has risen, <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia">so have harms</a>. Opioids are the <a href="https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-induced-deaths-australia-1997-2019">main drug involved</a> in drug-induced deaths.</p>
<p>Pharmaceutical opioids are now involved in <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">more deaths than heroin</a>. Pharmaceutical opioids also contribute more to <a href="https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-related-hospitalisations-australia-1999-2019">poisoning-related hospital visits</a> than heroin, with hospitalisations doubling since 1999. </p>
<h2>So what did our research find?</h2>
<p>In <a href="https://www.sciencedirect.com/science/article/abs/pii/S095539592200127X">our study</a>, one in five people reported problems relating to accessing doctors. </p>
<p>As opioids become more restricted, people may need to visit their doctor more frequently because they’re given smaller pack sizes and fewer repeats. They may be put in a position where they’re unable to get prescriptions if doctors aren’t available. </p>
<p>Opioids can cause <a href="https://pubmed.ncbi.nlm.nih.gov/14640337/">dependence</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628209/">tolerance</a> with continuous and long-term use. However, sudden interruptions to opioid medicine supply may place people at risk of experiencing <a href="https://pubmed.ncbi.nlm.nih.gov/31986228/">unpleasant withdrawal symptoms</a> such as nausea and vomiting, flu symptoms, and muscle cramping.</p>
<p>One in ten people in our study reported their doctor wanted to reduce or stop opioid medicines against their wishes. </p>
<figure class="align-center ">
<img alt="Older man holding a glass of water takes tablets in his hands." src="https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ceasing opioids needs to be undertaken carefully.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-man-young-girl-home-granddaughter-2128075508">Shutterstock</a></span>
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</figure>
<h2>Patients and doctors need to work together</h2>
<p>More doctors are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902834/">practising</a> “opioid tapering” (reducing opioid doses over time), especially in the United States, <a href="https://pubmed.ncbi.nlm.nih.gov/33515197/">following</a> the release in 2016 of Centers for Disease Control and Prevention (CDC) <a href="https://jamanetwork.com/journals/jama/fullarticle/2503508">guidelines</a> for chronic pain. </p>
<p>However, there were soon reports of opioids being ceased <a href="https://pubmed.ncbi.nlm.nih.gov/32844498/">without</a> <a href="https://pubmed.ncbi.nlm.nih.gov/31079950/">reducing the dose first</a>, which risks withdrawal. This <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1904190">prompted the CDC to warn</a> that applying guidelines without adequate care could harm patients.</p>
<p>Worryingly, studies have linked stopping or reducing opioids with death by <a href="https://pubmed.ncbi.nlm.nih.gov/33863865/">suicide</a> <a href="https://pubmed.ncbi.nlm.nih.gov/31468341/">and</a> <a href="https://pubmed.ncbi.nlm.nih.gov/34342618/">overdose</a>, even for <a href="https://www.annfammed.org/content/20/Supplement_1/2871.abstract">people prescribed opioids at low doses</a> to begin with. </p>
<p>These studies also found people who stopped opioids were more likely to visit the emergency department or be admitted to hospital for <a href="https://pubmed.ncbi.nlm.nih.gov/34342618/">mental health crises</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/33863865">illicit drug use</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/31079950/">overdoses</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-script-changes-mean-well-but-have-left-some-people-in-chronic-pain-156753">Opioid script changes mean well, but have left some people in chronic pain</a>
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<hr>
<p>For some people, reducing or stopping opioids will be the right thing for them, clinically. Some studies suggest <a href="https://link.springer.com/article/10.1007/s11606-020-06253-8">stopping opioids can be done</a> without <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993952/">increasing pain</a>. </p>
<p>Some studies suggest <a href="https://www.mja.com.au/journal/2021/214/9/opioid-cessation-associated-reduced-pain-and-improved-function-people-attending">pain may even improve</a> when <a href="https://pubmed.ncbi.nlm.nih.gov/31764391/">opioids are stopped</a>. However, participants in these studies are usually enrolled in special pain programs. These programs are notoriously difficult to access in Australia and it is <a href="https://pubmed.ncbi.nlm.nih.gov/33106875/">common to wait months to years</a> for services.
<a href="https://www.painaustralia.org.au/federal-budget-more-mbs-items-needed-for-people-with-chronic-pain">Increased investment</a> in pain services and programs is needed. </p>
<p>There is also a need for opioid tapering to be undertaken in a <a href="https://pubmed.ncbi.nlm.nih.gov/33012347/">collaborative way</a>, with patients and doctors working as a team to achieve <a href="https://pubmed.ncbi.nlm.nih.gov/34382602/">agreed upon goals</a>. </p>
<h2>Balancing benefits and harms</h2>
<p>Since we conducted our study, new <a href="https://www.nps.org.au/radar/articles/opioids-new-and-amended-pbs-listings">restrictions introduced</a> in 2020 reduced the quantities of opioids that can be prescribed on the PBS. For most opioids, doctors can only supply quantities and repeats for up to three months at a time. </p>
<p>So it’s likely to have become harder for people with pain to access pain medicines. In a survey released last month by Painaustralia, half of the respondents said <a href="https://www.painaustralia.org.au/static/uploads/files/painaustralia-impact-of-opioid-regulatory-reforms-on-people-living-with-chronic-pai-wfopkycfkmnq.pdf">their pain management was worse</a>, and their pain was more severe, because of the changes. </p>
<figure class="align-center ">
<img alt="Woman talks to doctor via a smartphone" src="https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid harms need to be recognised and addressed, as does pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-patient-conversation-specialist-over-1943749642">Shutterstock</a></span>
</figcaption>
</figure>
<p>When it comes to using opioids for chronic non-cancer pain, it’s important to balance both benefits and harms. Potential opioid-related harms need to be recognised and addressed. At the same time, adequate treatment of pain is essential, and we need to make sure people don’t suffer harms due to changes to opioid access. </p>
<p>The needs of people who live with pain and the impact of restrictions on them need to remain at the centre of all decisions and discussions about opioids.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/patients-leaving-hospital-sometimes-need-opioids-doctors-can-reduce-risks-of-long-term-use-and-dependence-181941">Patients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence</a>
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</p>
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<img src="https://counter.theconversation.com/content/182678/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ria Hopkins receives funding from the Australian National Health and Medical Research Council (NHMRC).
</span></em></p><p class="fine-print"><em><span>Natasa Gisev does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Measures to curb growing rates of opioid use are also making it difficult for people with long-term, chronic pain to get ongoing prescriptions.Ria Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyNatasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1785912022-04-11T19:01:35Z2022-04-11T19:01:35ZEndometriosis: How advocacy, awareness and algorithms could shorten the long wait for diagnosis and treatment<figure><img src="https://images.theconversation.com/files/456541/original/file-20220406-22-icfn7.jpg?ixlib=rb-1.1.0&rect=409%2C34%2C5119%2C3438&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite the prevalence of endometriosis, people often live with pain and other symptoms for years before being diagnosed.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/endometriosis--how-advocacy--awareness-and-algorithms-could-shorten-the-long-wait-for-diagnosis-and-treatment" width="100%" height="400"></iframe>
<p>Endometriosis affects an estimated <a href="https://www.endofound.org/endometriosis">200 million people worldwide</a>. Despite its prevalence, those living with the disease often wait an average of <a href="https://doi.org/10.1177%2F1750481318771430">7.5 years</a> between start of symptoms and diagnosis. This delay is due to a variety of reasons, including <a href="https://theconversation.com/endometriosis-three-reasons-care-still-hasnt-improved-157457">medical dismissal, a low prioritization of the condition and its overall misrepresentation</a> in research funding, policy and media.</p>
<p>Although often represented as a women’s reproductive disease, endometriosis also appears in people who have had hysterectomies, transgender men, genderfluid and non-binary people, pre-menstrual and post-menopausal people, and in rare cases, <a href="https://doi.org/10.1016/j.prp.2011.10.007">cisgender men</a>. </p>
<p>Its symptoms commonly include pain with menstruation, as well as chronic pain, infertility, pain with sexual intercourse, fatigue and more. Despite this full-body impact on one’s <a href="https://doi.org/10.1016/j.fertnstert.2011.05.090">quality of life</a>, endometriosis is commonly associated with just having “bad periods.”</p>
<p>We are four authors from three countries looking at different aspects of endometriosis diagnosis, awareness and patient advocacy. This article emerges from a <a href="https://www.eventbrite.com/e/young-people-endometriosis-social-perspectives-on-the-delay-to-diagnosis-tickets-237420941427#">joint online presentation</a> of our research looking at potential ways to improve awareness and patient care, and promote faster diagnosis.</p>
<p>Our methods include social scientific and qualitative research including interviews, surveys, focus groups, participant observations and collaborations with people living with endometriosis. We identified some clear changes that are needed to promote awareness of the disease, and subsequently reduce diagnostic timelines.</p>
<h2>Widespread endometriosis education</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A powerpoint slide showing the results of Maria Tomlinson's survey and quotes from young people about endometriosis." src="https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=334&fit=crop&dpr=1 600w, https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=334&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=334&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=420&fit=crop&dpr=1 754w, https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=420&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/452013/original/file-20220314-15-2ebu8u.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=420&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Maria Tomlinson’s research surveyed young people about their awareness and knowledge of endometriosis.</span>
<span class="attribution"><span class="source">(Maria Kathryn Tomlinson)</span>, <span class="license">Author provided</span></span>
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</figure>
<p>Our research suggests that endometriosis education is severely lacking, meaning that many people who have the condition do not even know it exists. </p>
<p>In focus groups with 77 16- to 19-year-olds in the United Kingdom, Maria found that only 28 had heard of endometriosis before. Of these, two were able to accurately define it. Most of those who had heard of the disease had done so through friends and family, with some also hearing about it on social media or the internet. None of them had been told about it in their formal education.</p>
<p>Eileen’s survey of 271 people with endometriosis showed that only nine people (3.3 per cent) heard about endometriosis from grade school (elementary, junior or high school) with a few mentioning that they had heard about it briefly in nursing school.</p>
<p>Although Eileen’s interviews and surveys showed that social media can be very beneficial to people who live with endometriosis, Maria’s focus groups showed that social media is not very effective at reaching people who do not have the condition. People with endometriosis often put enormous amounts of work into <a href="https://theconversation.com/what-is-endometriosis-patients-turn-to-social-media-for-information-and-support-160852">sharing endometriosis information online</a>, but it often does not reach the broader population.</p>
<h2>Accurately represent menstrual pain and endometriosis pain</h2>
<p>As Mie identifies in her fieldwork on menstruation among teenagers and interviews with endometriosis patients from Denmark, the normalization of menstrual pain is one of the main factors delaying diagnosis for people with endometriosis. </p>
<p>Although not everyone who has endometriosis menstruates or has menstrual pain, <a href="https://doi.org/10.1177/0884217503261085">it is one of the most common and symptoms, and one of the earliest</a>. Many people are encouraged to use painkillers and hormonal contraceptives to manage their pain, instead of having it investigated. Being prescribed birth control pills without a thorough investigation of symptoms, or consideration for gender identity, were also concerns identified by participants in Maria’s focus groups.</p>
<figure class="align-center ">
<img alt="Cropped image of a pharmacist's hands holding birth control pills with a woman seen from behind" src="https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456542/original/file-20220406-21-lb9ifc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many people are encouraged to use painkillers and hormonal contraceptives to manage their pain instead of having it investigated.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Maria’s participants also explained how they believe menstrual product advertisements undermined the severity of menstrual pain. They thought that more realistic representations of painful periods might encourage more young people with periods to seek medical help when needed. </p>
<p>Mie’s work identifies the often cyclical nature of endometriosis symptoms as something that can discourage patients from seeking care, as they feel their symptoms are not as extreme when they are not menstruating. Better awareness that cyclical symptoms can also indicate diseases might help patients seek care earlier.</p>
<p>Eileen’s social media analysis shows that people with endometriosis often use social media to represent their lived experiences of menstrual pain and endometriosis with complexity, in contrast to common media representations. </p>
<figure class="align-center ">
<img alt="A word cloud resonding to the question 'What does 'endometriosis' mean to you?' The most prominent words are pain, time and life." src="https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&rect=12%2C6%2C1172%2C661&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/452010/original/file-20220314-130173-ynrimv.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A word cloud responding to the question, ‘What does endometriosis mean to you?’</span>
<span class="attribution"><span class="source">(Eileen Mary Holowka)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In a recent example, Amy Corfeli from the podcast and social media platform <a href="https://www.instagram.com/p/CasRLDBuR52/">@in16yearsofendo</a> used Instagram, Twitter and <a href="https://medium.com/@amycorfeli/dear-greys-anatomy-your-endometriosis-info-needs-updating-4fbb942e616b"><em>Medium</em></a> to address inaccuracies in the television show <em>Grey’s Anatomy</em>’s representation of endometriosis. Unfortunately, <em>Grey’s Anatomy</em> has a larger platform, but social media pages like Amy’s, <a href="https://www.instagram.com/endoqueer/">@endoQueer</a> and <a href="https://www.instagram.com/endo_black/">@endo_black</a> attempt to bring more nuance and diversity into the media depictions of endometriosis.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CasRLDBuR52","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<h2>Improving diagnostic time</h2>
<p>Endometriosis is an “invisible” condition, meaning it cannot be seen by just looking at someone. Including endometriosis in grade school curricula, covering it more extensively in medical school, and representing it more broadly in media, would help make the disease more apparent so people with symptoms seek care sooner.</p>
<p>However, the burden of care cannot be on patients alone, particularly for a condition like endometriosis which comes with <a href="https://endometriosis.org/resources/clinical-books/googling-endometriosis-david-redwine/">a long history of patient-blaming</a>. Interventions are needed on the medical side, but limited resources, long wait times, suboptimal diagnostic techniques and knowledge, and the low prioritization of endometriosis all <a href="https://theconversation.com/1-in-10-women-are-affected-by-endometriosis-so-why-does-it-take-so-long-to-diagnose-141803">increase diagnostic delays</a>. </p>
<p>It is possible that interventions such as the <a href="https://findingendometriosis.eu/">FEMaLe</a> (Finding Endometriosis using Machine Learning) project, co-ordinated by Ulrik, could help improve diagnosis in the future. This project, emerging out of Denmark, aims to develop and demonstrate a platform that uses algorithms to detect and help diagnose and treat people with endometriosis, in collaboration with their health-care providers. </p>
<p>In order to develop this kind of work, a multidisciplinary approach to endometriosis is needed, including not only medical research, but also the kind of qualitative work outlined in this story.</p><img src="https://counter.theconversation.com/content/178591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eileen Mary Holowka receives funding from the Canadian Social Sciences and Humanities Research Council and is a member of the Endometriosis Educational Organization of Canada.</span></em></p><p class="fine-print"><em><span>Dr. Maria Kathryn Tomlinson receives funding from the Leverhulme Trust under Grant ECF-2019-232. Her project is entitled "Menstrual Activism in the Media: Reducing Stigma and Tackling Inequalities".</span></em></p><p class="fine-print"><em><span>Mie Kusk Søndergaard receives funding from the Danish Cancer Society and University of Southern Denmark. She has previously collaborated with the Danish endometriosis association Endometriose Foreningen. </span></em></p><p class="fine-print"><em><span>Ulrik Bak Kirk receives funding from the EU under the H2020 Research and Innovation Action for the 'Finding Endometriosis using Machine Learning' (FEMaLe) project (grant agreement ID: 101017562).</span></em></p>People living with endometriosis wait an average of 7.5 years for a diagnosis. Social science researchers are working to identify ways to help reduce this timeline.Eileen Mary Holowka, PhD Candidate, Communication Studies, Concordia UniversityMaria Kathryn Tomlinson, Leverhulme Early Career Researcher, Department of Journalism Studies, University of SheffieldMie Kusk Søndergaard, PhD fellow, Department of Public Health, University of Southern DenmarkUlrik Bak Kirk, PhD Fellow, FEMaLe Coordinator, Aarhus UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1719362022-02-13T23:07:18Z2022-02-13T23:07:18ZOpioids ease osteoarthritis pain only slightly. Their deadly risks need to be weighed against any benefit<figure><img src="https://images.theconversation.com/files/435535/original/file-20211203-13-13m355a.jpg?ixlib=rb-1.1.0&rect=13%2C13%2C4564%2C2560&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/white-prescription-pills-spilled-onto-260nw-747676462.jpg">Shutterstock</a></span></figcaption></figure><p>Osteoarthritis is one of the leading causes of disability, <a href="https://pubmed.ncbi.nlm.nih.gov/31034380/">affecting more than 500 million people globally</a>. </p>
<p>Most doctors encourage physical activity, maintaining a healthy weight and short-term use of a simple painkiller like paracetamol to manage the pain. </p>
<p>Opioids, like codeine, morphine or oxycodone, have a reputation as powerful painkillers and are commonly prescribed for persistent osteoarthritis pain. Up to 40% of people with knee osteoarthritis in the US are <a href="https://pubmed.ncbi.nlm.nih.gov/33629485/">treated with opioid medicines</a>. </p>
<p>People who begin taking opioid medicines to treat chronic pain conditions like osteoarthritis may end up taking them on an ongoing basis and expose themselves to serious harms including <a href="https://www.bmj.com/content/367/bmj.l6691">dependence, overdose and even death</a>. </p>
<p>In Australia, deaths from opioids <a href="https://www.abc.net.au/news/health/2019-08-27/accidental-drug-overdoses-forecast-to-reach-record-high/11450764">now exceed the national road toll</a>. </p>
<p>In our new study, <a href="https://www.mja.com.au/journal/2022/216/6/efficacy-safety-and-dose-dependence-analgesic-effects-opioid-therapy-people">published today</a>, we reviewed all the relevant research and found opioids only offer very small benefits for the relief of osteoarthritis pain. Patients – and their doctors – need to carefully weigh up the risks and benefits of taking these commonly prescribed medicines for the treatment of osteoarthritis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-5-aussies-over-45-live-with-chronic-pain-but-there-are-ways-to-ease-the-suffering-137891">1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering</a>
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</em>
</p>
<hr>
<h2>Small shifts on the pain scale</h2>
<p>Opioids are types of narcotic drugs that work on the central nervous system to relieve pain. Our team from the University of Sydney and <a href="https://imh.org.au/">Sydney Musculoskeletal Health</a> conducted a large review of 36 randomised controlled trials that compared opioid medicines to a placebo (or inactive pill) for osteoarthritis pain of the knee or hip. This kind of review represents the highest level of research evidence. </p>
<p>The combined trial results show the overall effects of opioid medicines compared to placebo on important outcomes such as pain and function. </p>
<p>The review found opioid medicines provide a very small improvement in pain and function compared with placebo. This improvement amounted to approximately 5 points or less on a 0 (no pain) to 100 (worst pain imaginable) pain scale. These modest effects are similar to what is expected if <a href="https://www.mja.com.au/journal/2021/214/7/efficacy-and-safety-paracetamol-pain-relief-overview-systematic-reviews">using paracetamol for osteoarthritis</a> and less than one-third as effective as <a href="https://www.bmj.com/content/372/bmj.n104.long">certain non-steroidal anti-inflammatory pills or creams</a> including ibuprofen.</p>
<p>Our findings add weight to other research into the effectiveness of opioids. Australian researchers <a href="https://www.theguardian.com/australia-news/2021/nov/18/strong-opioids-not-better-than-milder-painkillers-after-surgery-for-fractures-study-finds">observed</a> late last year that opioids were no more effective than mild painkillers after surgery for fracture.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5226%2C3473&q=45&auto=format&w=1000&fit=clip"><img alt="man holds sore knee" src="https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5226%2C3473&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435534/original/file-20211203-13-ongkvz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Patients may get just as much pain relief from paracetamol or ibuprofen.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/close-man-sitting-holding-his-260nw-1379226200.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-script-changes-mean-well-but-have-left-some-people-in-chronic-pain-156753">Opioid script changes mean well, but have left some people in chronic pain</a>
</strong>
</em>
</p>
<hr>
<h2>More was not more effective</h2>
<p>Importantly, we found no significant link between the dosage amount of opioid medicine and the level of pain relief. So, if an opioid medicine isn’t helping manage pain, increasing the dose is not likely to provide any further benefit. </p>
<p>The harms of opioids are well known, particularly at higher doses. Common side effects include nausea, constipation and fatigue. The <a href="https://www.mja.com.au/journal/2022/216/6/efficacy-safety-and-dose-dependence-analgesic-effects-opioid-therapy-people">review</a> revealed the risk of experiencing unwanted effects like these when taking an opioid is almost 1.5 times greater than when taking a placebo.</p>
<p>Opioids also carry a risk of <a href="https://pubs.asahq.org/anesthesiology/article/124/2/483/12697/Differential-Opioid-Tolerance-and-Opioid-induced">tolerance</a>, which happens when the current dose is no longer helpful in managing the pain and a larger dose is needed to achieve the same effect. </p>
<p>These medicines can also lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/">dependence</a>, where stopping the opioid suddenly can lead to unpleasant withdrawal symptoms such as an inability to sleep, agitation, sweating and heart palpitations. </p>
<p>The risk of life-threatening overdose events is high with regular use of opioid medicines, as opioids inhibit the part of the brain that regulates our breathing. Opioids are the <a href="https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-induced-deaths-australia-1997-2019">most common cause of drug-induced deaths in Australia</a>, with 1,121 deaths reported in 2019 alone. The majority of these deaths (around 56%) resulted from prescription opioid medicines rather than illicit opioids such as heroin. </p>
<p>Scientists are working on <a href="https://www.eurekalert.org/news-releases/935738">new pain-relieving compounds</a> that activate opioids receptors but are safer for patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/designing-less-addictive-opioids-through-chemistry-163557">Designing less addictive opioids, through chemistry</a>
</strong>
</em>
</p>
<hr>
<h2>Patients get hooked and fast</h2>
<p>In the past few years, growing evidence has revealed taking opioid medicines for just a short amount of time can lead to persistent use. </p>
<p>About 24% of patients who use opioid medicines for 12 days will <a href="https://www.bmj.com/content/367/bmj.l6691">continue to use opioids for at least a year</a>. This goes up to 43% after just one month of opioid use. </p>
<p>With long-term use, the risk of adverse effects is greatly increased, especially as it is likely people will need higher doses to achieve the same level of pain control. </p>
<p>Chronic pain conditions like osteoarthritis are also commonly treated with long-acting formulations of opioid medicines such as OxyContin. However these types of opioids, which are intended to be taken regularly instead of only when needed, are associated with a <a href="https://www.bmj.com/content/367/bmj.l6691">six-fold increased risk of overdose</a> compared with short-acting formulations.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1460986935707590665"}"></div></p>
<h2>Choose wisely</h2>
<p>Our new findings will provide people with realistic expectations about the benefits these drugs can provide for chronic pain. Then they can carefully weigh this up with the risks. </p>
<p>Opioid medicines provide modest benefits for osteoarthritis which is similar to, or considerably less than, more simple analgesics like paracetamol or ibuprofen. </p>
<p>If you do choose or are prescribed to start an opioid medicine, discuss the benefits and potential harms with a doctor first. If you are concerned about the amount of opioid medicines you are using, or the duration you have been using them, speak with your doctor about a <a href="https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf">dose-reduction plan</a>.</p><img src="https://counter.theconversation.com/content/171936/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina Abdel Shaheed receives funding from the National Health and Medical Research Council</span></em></p><p class="fine-print"><em><span>Christopher Maher holds funding from Government (e.g NHMRC) and not-for-profit agencies (e.g HCF Research Foundation) to support investigator-initiated research. </span></em></p><p class="fine-print"><em><span>Wasim Awal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We researched how much difference opioids like codeine, oxycodone or morphine make to osteoarthritis pain. We found they helped about as much as paracetamol. Yet they are far more dangerous.Wasim Awal, Doctor of Medicine, Griffith UniversityChristina Abdel Shaheed, Early Career Development Fellow, School of Public Health, University of SydneyChristopher Maher, Professor, Sydney School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738452022-02-11T13:34:32Z2022-02-11T13:34:32ZIn research studies and in real life, placebos have a powerful healing effect on the body and mind<figure><img src="https://images.theconversation.com/files/445014/original/file-20220208-19-1dce055.jpg?ixlib=rb-1.1.0&rect=38%2C76%2C5078%2C3322&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The concept of placebos – which are sometimes called "sugar pills" – has been around since the 1800s.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pharmaceutical-research-conceptual-image-royalty-free-image/185760489?adppopup=true">Wladimir Bulgar/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Did you ever feel your own shoulders relax when you saw a friend receive a shoulder massage? For those of you who said “yes,” congratulations, your brain is using its power to create a “placebo effect.” For those who said “no,” you’re not alone, but thankfully, the brain is trainable. </p>
<p>Since the 1800s, <a href="https://doi.org/10.1001/jama.1955.02960340022006">the word placebo</a> has been used to refer to a fake treatment, meaning one that does not contain any active, physical substance. You may have heard of placebos referred to as “sugar pills.” </p>
<p>Today, placebos play a crucial role in medical studies in which some participants are given the treatment containing the active ingredients of the medicine, and others are given a placebo. These types of studies help tell researchers which medicines are effective, and how effective they are. Surprisingly, however, in some areas of medicine, placebos themselves provide patients with <a href="https://doi.org/10.1016/S0140-6736(09)61706-2">clinical improvement</a>. </p>
<p>As two psychologists interested in how <a href="https://scholar.google.com/citations?hl=en&user=LFOKsvwAAAAJ&view_op=list_works&gmla=AJsN-F7HTmfem-T2-tGORhXc3ZwClbf_3X8_ap-HWeyTOTMcJPTzWkutZ6ZL85CJwi2v87spWvAQmnmkjzKIh4ULAdFAV8KVFSBRBC6VQ8ky36RvnyreDoY">psychological factors affect physical conditions</a> and <a href="https://ihpi.umich.edu/our-experts/schrodeh">beliefs about mental health</a>, we help our patients heal from various <a href="https://ihpi.umich.edu/our-experts/ehpatter">threats to well-being</a>. Could the placebo effect tell us something new about the power of our minds and how our bodies heal?</p>
<h2>Real-life placebo effects</h2>
<p>Today, scientists define these <a href="http://programinplacebostudies.org/">so-called placebo effects</a> as the positive outcomes that cannot be scientifically explained by the physical effects of the treatment. Research suggests that the placebo effect is caused by <a href="https://doi.org/10.1038/nrn3976">positive expectations</a>, the provider-patient relationship and the <a href="https://doi.org/10.1016/S0140-6736(09)61706-2">rituals around receiving medical care</a>.</p>
<p>Depression, pain, fatigue, allergies, <a href="https://doi.org/10.1186/s13063-017-1964-x">irritable bowel syndrome</a>, Parkinson’s disease and even <a href="https://doi.org/10.1056/nejmoa013259">osteoarthritis of the knee</a> are just <a href="https://doi.org/10.1159/000490354">a few of the conditions</a> that <a href="https://www.npr.org/2020/05/11/853753307/all-the-worlds-a-stage-including-the-doctor-s-office">respond positively to placebos</a>. </p>
<p>Despite their effectiveness, there is stigma and debate about <a href="https://doi.org/10.1159/000514435">using placebos in U.S. medicine</a>. And in routine medical practice, they are rarely used on purpose. But based on new understanding of how non-pharmacological aspects of care work, safety and patient preferences, some experts have begun recommending <a href="https://doi.org/10.1159/000490354">increasing the use of placebos in medicine</a>.</p>
<p>The U.S. Food and Drug Administration, the organization that regulates which medicines are allowed to go to the consumer market, requires that all new medicines be tested in randomized controlled trials that show they are <a href="https://www.regdesk.co/fdas-guidance-on-placebos/#">better than placebo treatments</a>. This is an important part of ensuring the public has access to high-quality medications. </p>
<p>But studies have shown that the placebo effect is so strong that many drugs don’t provide more relief <a href="https://doi.org/10.1017/S2045796018000240">than placebo treatments</a>. In those instances, drug developers and researchers sometimes see placebo effects as a nuisance that masks the treatment benefits of the manufactured drug. That sets up an incentive for drug manufacturers to try to do away with placebos so that drugs pass the FDA tests.</p>
<p>Placebos are such a problem for the enterprise of drug development that a company has developed a <a href="https://verasci.com/the-placebo-control-reminder-script-now-available-on-pathway/">coaching script to discourage patients</a> who received placebos from <a href="https://doi.org/10.1038/s41386-020-00911-5">reporting benefits</a>.</p>
<h2>Treating depression</h2>
<p>Prior to the COVID-19 pandemic, about 1 in 12 U.S. adults had a <a href="https://www.cdc.gov/nchs/products/databriefs/db303.htm">diagnosis of depression</a>. During the pandemic, those numbers rose to <a href="https://www.bu.edu/articles/2021/depression-rates-tripled-when-pandemic-first-hit/">1 in 3 adults</a>. That sharp rise helps explain why <a href="https://www.businesswire.com/news/home/20210426005303/en/Global-Antidepressants-Market-Report-2021-COVID-19-Causes-a-Surge-in-Demand-for-Antidepressant-Drugs-as-Mental-Health-Problems-Rise---ResearchAndMarkets.com">US$26.25 billion worth of antidepressant medications</a> were used across the globe in 2020.</p>
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<figcaption><span class="caption">Brain-imaging studies show that the brain has an identifiable response to the expectations and context that come with placebos.</span></figcaption>
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<p>But according to psychologist and placebo expert Irving Kirsch, who has studied placebo effects for decades, a large part of <a href="https://doi.org/10.3389/fpsyt.2019.00407">what makes antidepressants helpful</a> in alleviating depression is the placebo effect – in other words, the belief that the medication will be beneficial. </p>
<p>Depression is not the only condition for which medical treatments are actually functioning at the level of placebo. Many well-meaning clinicians offer treatments that appear to work based on the fact that patients get better. But a recent study reported that <a href="https://www.sciencealert.com/around-90-percent-of-your-medical-treatments-isn-t-backed-by-high-quality-evidence">only 1 in 10</a> <a href="https://doi.org/10.1016/j.jclinepi.2020.08.005">medical treatments sampled</a> met the standards of what is considered by some to be the gold standard of high quality evidence, according to <a href="https://www.cochrane.org/evidence">a grading system</a> by an international nonprofit organization. This means that many patients improve even though the treatments they receive have not actually been proved to be better than the placebo. </p>
<h2>How does a placebo work?</h2>
<p>The power of the placebo comes down to the power of the mind and a person’s skill at harnessing it. If a patient gets a <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/tension-headaches">tension headache</a> and their trusted doctor gives them a medicine that they feel confident will treat it, the relief they expect is likely to decrease their stress. And since <a href="https://www.mayoclinic.org/diseases-conditions/tension-headache/in-depth/headaches/art-20046707">stress is a trigger for tension headaches</a>, the magic of the placebo response is not so mysterious anymore.</p>
<p>Now let’s say that the doctor gives the patient an expensive brand-name pill to take multiple times per day. Studies have shown that it is even more likely to make them feel better because all of those elements subtly convey the message that they <a href="https://doi.org/10.1016/bs.irn.2018.07.014">must be good treatments</a>.</p>
<p>Part of the beauty of placebos is that <a href="https://www.nytimes.com/2016/01/25/books/review-in-cure-accepting-the-minds-role-in-a-bodys-health.html">they activate existing systems</a> of <a href="https://www.aapb.org/i4a/pages/index.cfm?pageID=3386">healing within the mind and body</a>. Elements of the body once thought to be outside of an individual’s control are now known to be modifiable. A legendary example of this is Tibetan monks who <a href="https://doi.org/10.1371/journal.pone.0058244">meditate to generate enough body heat</a> to dry wet sheets in 40-degree Fahrenheit temperatures.</p>
<p>A field called <a href="https://bensonhenryinstitute.org/mission-history/">Mind Body Medicine</a> developed from the work of cardiologist Herbert Benson, who observed those monks and other experts mastering control over automatic processes of the body. It’s well understood in the medical field that <a href="https://us.macmillan.com/books/9780805073690#">many diseases are made worse</a> by the automatic changes that <a href="https://www.hsph.harvard.edu/nutritionsource/stress-and-health/">occur in the body under stress</a>. If a placebo interaction reduces stress, it can <a href="https://www.apa.org/topics/stress/body#">reduce certain symptoms</a> in a scientifically explainable way. </p>
<p>Placebos also work by creating expectations and conditioned responses. Most people are familiar with <a href="https://pubmed.ncbi.nlm.nih.gov/29262194/">Pavlovian conditioning</a>. A bell is rung before giving dogs meat that makes them salivate. Eventually, the sound of the bell causes them to salivate even when they do not receive any meat. A recent study from Harvard Medical School successfully used the same conditioning principle to help patients <a href="https://doi.org/10.1097/j.pain.0000000000002185">use less opioid medication for pain following spine surgery</a>. </p>
<p>Furthermore, multiple brain imaging studies demonstrate changes in the brain in response to successful placebo treatments for pain. This is excellent news, given the <a href="https://theconversation.com/oxycontin-created-the-opioid-crisis-but-stigma-and-prohibition-have-fueled-it-167100">ongoing opioid epidemic</a> and the need for effective pain management tools. There is even evidence that individuals who respond positively to placebos <a href="https://doi.org/10.1126/science.1093065">show increased activity in areas of the brain</a> that release naturally occurring opioids. </p>
<p>And emerging research suggests that even when people know they are receiving a placebo, the inactive treatment still has <a href="https://doi.org/10.1038/s41467-020-17654-y">effects on the brain and reported levels of improvement</a>. </p>
<h2>Placebos are nontoxic and universally applicable</h2>
<p>In addition to the ever-increasing body of evidence surrounding their effectiveness, placebos offer multiple benefits. They have no side effects. They are cheap. They are not addictive. They provide hope when there might not be a specific chemically active treatment available. They mobilize a person’s own ability to heal through multiple pathways, including those studied in the <a href="https://www.pnirs.org/">field of psychoneuroimmunology</a>. This is the study of relationships between the immune system, hormones and the nervous system. </p>
<p>By defining a placebo as the act of setting positive expectations and providing hope through psychosocial interactions, it becomes clear that placebos can enhance traditional medical treatments.</p>
<h2>Using placebos to help people in an ethical way</h2>
<p>The placebo effect is recognized as being powerful enough that the American Medical Association considers it <a href="https://www.ama-assn.org/delivering-care/ethics/use-placebo-clinical-practice#">ethical to use placebos</a> to enhance healing on their own or with standard medical treatments if the patient agrees to it.</p>
<p>Clinically, doctors use the principles of placebo in a more subtle way than it is used in research studies. A 2013 study from the U.K. found that <a href="https://doi.org/10.1371/journal.pone.0058247">97% of physicians</a> acknowledged in a survey having used some form of placebo during their career. This might be as simple as expressing a strong belief in the likelihood that a patient will feel better from whatever treatment the doctor prescribes, even if the treatment itself is not chemically powerful. </p>
<p>There is now even an international <a href="https://placebosociety.org/home">Society for Interdisciplinary Placebo Studies</a>. They have written <a href="https://doi.org/10.1159/000490354">a consensus statement</a> about the use of placebos in medicine and recommendations for <a href="https://doi.org/10.1159/000510738">how to talk with patients about it</a>. In the past, patients who improved from a placebo effect might have felt embarrassed, as if their ailment were not real. </p>
<p>But with the medical field’s growing acceptance and promotion of placebo effects, we can envision a time when patients and clinicians take pride in their skill at harnessing the placebo response.</p>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Drug manufacturers often shun the use of placebos in clinical trials. But research suggests that placebos could play an important role in the treatment of depression, pain and other maladies.Elissa H. Patterson, Clinical Assistant Professor of Psychiatry and Neurology, University of MichiganHans Schroder, Clinical Assistant Professor of Psychiatry, University of MichiganLicensed as Creative Commons – attribution, no derivatives.